Risk for Infection and Risk for Trauma - NCP for Encephalitis

Nursing Care Plan for Encephalitis

Encephalitis is an infection of the CNS caused by viruses or other micro-organisms are non-purulent.

Pathogenesis of encephalitis

Viruses enter the patient's body through the skin, respiratory tract and gastrointestinal tract. Upon entry into the body, the virus will spread throughout the body in several ways:
1 Local: limited flow viruses infect the mucous membrane or the surface of a particular organ.
2 Primary hematogenous Dissemination: the virus into the blood then spread to organs and breed in these organs.
3 Spread through the nerves: Surface viruses multiply in the mucous membranes and spreads through the nervous system.

Prodromal period lasts 1-4 days characterized by fever, headache, dizziness, vomiting, sore throat, malaise, pain in the extremities and pale.
Other symptoms such as anxiety, irritable, behavior changes, disturbance of consciousness, seizures.
Sometimes accompanied Neurological signs such as Aphasia, Hemiparesis, Hemiplegia, Ataxia, brain nerve paralysis.

Symptoms that may occur in Encephalitis:
Increased body heat, photo phobia, headache, vomiting, lethargy, sometimes accompanied by a stiff neck when the infection of the meninges.
Children looked nervous sometimes accompanied by changes in behavior. May be accompanied by impaired vision, hearing, speech and seizures.


Assessment

1. Identity
Encephalitis can occur in all age groups.

2 The main complaint
Increased body heat, seizures, decreased consciousness.

3. History of present illness
At first the child cranky, restless, vomiting, increased body heat approximately 1-4 days, headache.

4. Past medical history
Previous clients suffering from coughs, colds approximately 1-4 days, had suffered from herpes disease, infectious disease of the nose, ears and throat.

5. Family Health History
There families who suffer from diseases caused by viruses eg herpes etc.. Bacteria example: Staphylococcus aureus, Streptococcus, E-Coli, etc..

6 Immunization
When was the last given DTP immunization.
Because encephalitis can occur post pertussis immunization.
Growth and Development.


Nursing Diagnosis : Risk for Infection related to the body's resistance to infection down.

Goal: prevent infection

Criteria results:
Timely healing period without evidence of spread of infection endogenous.

Intervention
1. Defense aseptic technique and proper hand washing techniques either officers or visitors. Monitor and limit visitors.
R /: Reduce the risk of secondary infection. Controlling the spread of infection source.

2 Observations temperature regularly and clinical signs of infection.
R /. Early detection of signs of infection is an indication of the development of meningococcemia.

3 Give antibiotics as indicated.
R /. Drugs are selected depending on the type of infection and sensitivity of the individual.


Nursing Diagnosis : Risk for trauma related to generalized seizure activity.

Purpose: There was no trauma.

Criteria results:
Not having a seizure / other concomitant injuries.

Intervention:

1 Provide security for patients by giving pads, bed barriers remain attached and give a booster in the mouth, airway remains free.
R /: Protecting the patient in the event of a seizure, a booster mouth so that the tongue was not bitten.
Note: enter the mouth wedge mouth only when relaxation.

2 Maintain bed rest in the acute phase.
R /: Reduce the risk of falls / trauma during the vertigo.

Collaboration

3 Give the drug as indicated.
R /. An indication for the treatment and prevention of seizures.

4 Observation of vital signs.
R /: Detection of seizures themselves can be somewhat further action.

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7 Signs and Symptoms of Nasopharyngeal Carcinoma

Symptoms and signs are often found in nasopharyngeal cancer are:

1. Epistaxis: approximately 70% of patients experience these symptoms, including 23.2% of patients treated with these early symptoms. When sucking strongly secretions from the nasal cavity or nasopharynx, soft palate dorsal part rubbing against the surface of the tumor, so that the blood vessels in the tumor surface was torn and cause epistaxis. Arise mild epistaxis, severe nasal massive hemorrhage can occur.
2. Nasal congestion: often just next door and progressively intensified. This is due to a tumor of the posterior nostril clog.
3. Tinnitus and decreased hearing: the cause is a tumor in faringeus recess and the lateral wall of the nasopharynx infiltrate, pressing the eustachian tubes, causing negative pressures in the tympanic cavity, until there transudative otitis media. For patients with mild symptoms, actions dilatation eustachian tubes can relieve temporarily. The decline in hearing ability due to conduction barriers, generally accompanied by fullness in the ear.
4. Cephalalgia: uniqueness is a continuous pain in the temporoparietal region, or occipital one side. This is often due to the insistence of the tumor, infiltration of cranial nerves or cranial base bone, may also be due to local infection or irritation of the blood vessels which causes cephalalgia reflective.
5. Involuntary cranial nerve: nasopharyngeal cancer, and expansion infiltrate directly into the superior, destruction can cross the cranial base, or through channels or natural gaps cranial, go to petrosphenoid, of the fossa intracranial media (including foramen sphenotic, petrosis apex of the temporal bone, the foramen ovale, and the area spongiosus sine) makes the cranial nerves III, IV, V and VI involuntary, manifested by ptosis of the upper face, paralysis of the eye muscles (including the abduction of its own nerve paralysis), trigeminal neuralgia or temporal area pain due to irritation of the meninges (sphenoidal fissure syndrome), if there also involuntary second cranial nerve, called the orbital apex syndrome or petrosphenoid.
6. Enlarged lymph nodes of the neck: Typical location of lymph nodes metastases is the upper deep coli group, but because the lymph node groups covered surface sternocleidomastoid muscle, and the lump is not painful, it was initially difficult to know. There are some patients with metastatic lymph nodes perama appeared in the region of spiral strands coli accessory in the posterior triangl.
7. Symptoms of distant metastasis: the most frequent location of metastases to the bones, lungs, liver. The most common metastasis to the pelvic bones, vertebrae, ribs and all four extremities. Manifestation of bone metastases is a continuous pain and local tenderness, a fixed location and not arbitrary and gradually intensified. At this phase is not always there is a change in the X-ray, bone scan the entire body can help with the diagnosis. Liver metastases, lung can be very hidden, sometimes discovered when a routine follow-up is done by Xray thorax, liver examinations with CT or ultrasound.

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Disturbed Sleep Pattern, Knowledge Deficit and Anxiety - NCP Nasopharyngeal Carcinoma

Nursing Care Plan for Nasopharyngeal Carcinoma

Nasopharyngeal carcinoma is a malignant tumor derived from epithelial nasopharyngeal mucosa or glands found in the nasopharynx.

Nasopharyngeal carcinoma is the most carcinomas in the ENT.

It was found more in men than in women, with a ratio of 3: 1 by age / average age of 30 -50 years.


1. Nursing Diagnosis for Nasopharyngeal Carcinoma : Disturbed Sleep Pattern related to pain in the head.

Goal: Impaired sleep pattern of patients will be resolved.

Outcomes :

• Patients easily sleep within 30-40 minutes.
• Patients calm and fresh faces.
• Patients can express rested.

Interventions:
1 Create a comfortable and quiet environment.
Rationale: A comfortable environment can help improve sleep / rest.

2 Assess the patient's sleep habits at home.
Rationale: Knowing the change of the things that a patient when sleeping habits will affect the patient's sleep patterns.

3 Assess the causes of sleep disorders such as anxiety, effects of drugs and bustling atmosphere.
Rationale: Knowing the causes of other sleep disorders experienced and perceived patient.

4 Instruct the patient to use at bedtime and relaxation techniques.
Rational: Introduction to sleep will allow the patient to fall into sleep, relaxation techniques will reduce tension and pain.

5. Assess for signs of lack of sleep to meet the needs of patients.
Rationale: To determine whether requirements are met or the patient's sleep due to disruption of sleep patterns so that appropriate action can be taken.




2. Nursing Diagnosis for Nasopharyngeal Carcinoma : Knowledge Deficit: about the disease process, diet, care and treatment related to a lack of information.

Goal: Patient obtaining clear and correct information about the disease.

Outcomes :

• Patients learn about the disease process, diet, care and treatment and able to explain again if asked.
• Patients can perform self-care based on the knowledge gained.

Interventions:
1 Assess the level of knowledge of the patient / family about diabetes disease and Nasopharyngeal Cancer.
Rationale: To provide information on the patient / family, nurses need to know the extent to which the information or knowledge that is known to the patient / family.

2 Assess the patient's educational background.
Rationale: In order for nurses to provide explanations using words and sentences that can be understood according to the level of patient education patient.

3 Explain the disease process, diet, care and treatment in patients with language and words are easy to understand.
Rationale: In order for the information can be received easily and precisely so as to avoid misunderstandings.

4 Describe the procedure performed, the benefits to the patient and involve the patient.
Rationale: With explanatory and there and participate directly in the action taken, the patient will be more cooperative and less anxiety.

5 Use the images to provide an explanation (if there is / enable).
Rational: The pictures can help recall the explanation that has been given.



3. Nursing Diagnosis for Nasopharyngeal Carcinoma : Anxiety related to lack of knowledge about the disease.

Goal: anxiety is reduced / lost.

Outcomes :

• Patients can identify the cause of anxiety.
• Volatile emotions, calm the patient.
• Adequate rest.

Interventions:
1 Assess the level of anxiety experienced by the patient.
Rationale: To determine the level of anxiety experienced by patients so that nurses could provide rapid and appropriate intervention.

2 Give the opportunity for patients to express a sense of anxiety.
Rational: It can lighten the burden of the patient's mind.

3 Use therapeutic communication.
Rationale: To be built up trust between the nurse-patient so that the patient cooperative in nursing actions.

4 Give accurate information about the disease and encourage patients to participate in the act of nursing.
Rationale: Accurate information about the disease and the patient's participation in taking action to reduce the burden of the patient's mind.

5. Give confidence to patients that nurses, physicians, and other health team always strive to provide the best relief and optimal as possible.
Rationale: A positive attitude of the health care team will help reduce the anxiety felt by the patient.

6 Provide opportunities for families to accompany the patient in turn.
Rationale: The patient will feel calmer when there are family members who wait.

7 Create a quiet and comfortable environment.
Rationale: a quiet and comfortable environment can help reduce patient anxiety.

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Nursing Care Plan for Emphysema - Assessment and Diagnosis

Definition of Emphysema

Emphysema is a condition in which the alveoli become stiff expands and continuously filled the air even after expiration. (Kus Irianto.2004.216)

Emphysema is a chronic obstructive disease due to lack of elasticity in the lungs and alveoli surface area. (Corwin.2000.435)


Classification

There are two major types of emphysema, which are classified based on the changes that occur in the lungs:

1. Panlobular (panacinar), ie damage to the respiratory bronchi, alveolar ducts and alveoli. All air space in the little lobes much enlarged, with little inflammatory disease. The characteristics that have chest hyperinflation, and is characterized by dyspnea on exertion, and weight loss.
2. Centrilobular (centroacinar), the pathological changes mainly occur in the center of the secondary lobes, and peripheral of acini remain good. Often there is chaos-ventilation perfusion ratio, which lead to hypoxia, hypercapnia (increased CO2 in the arterial blood), polycythemia and heart failure episodes right. The condition leads to cyanosis, peripheral edema, and respiratory failure.

Etiology

Some things that can lead to pulmonary emphysema, namely:
1. Cigarette
Smoking can lead to pathological disorders of the airway ciliary movement, inhibits the function of alveolar macrophages, causing hypertrophy and hyperplasia of bronchial mucous glands.

2. Pollution
Industry and air pollutants can also cause emphysema. The incidence and mortality rates of emphysema can be said to be always higher in areas with high concentrations of industrialization, air pollution as well as tobacco smoke, can cause interference with cilia inhibits the function of alveolar macrophages.

3. Infection
Respiratory tract infections will cause more severe lung damage. Diseases such as respiratory infections, pneumonia, acute bronchiolitis and bronchial asthma, can lead to airway obstruction, which in turn can lead to emphysema.

4. Genetic

5. Exposure to dust


Clinical Manifestations

• Dyspnea.
• On inspection: chest shape 'barrel chest'.
• Chest breathing, abnormal breathing is not effective, and the use of accessory muscles of respiration (sternocleidomastoid).
• On percussion: hyperresonance and decreased fremitus in all lung fields.
• On auscultation: audible breath sounds with crackles, and expiratory length.
• Anorexia, weight loss, and general weakness.
• Distended neck veins during expiration.

Pathophysiology

Pulmonary emphysema is a lung development, accompanied by tearing of the alveoli that can not be recovered, can be either global or localized, the majority know the whole lung.

Charging excessive air with obstruction, occurs as a result of partial obstruction of the bronchi or bronchioles where the output of the air in the alveoli become more difficult than the input. In such a situation occurs that increases the accumulation of air in the distal alveoli.

In emphysema the narrowing of the airways, it can lead to narrowing of the airway obstruction and tightness, constriction of the airways caused by reduced lung elasticity.


Complication

• Frequent infections of the respiratory tract.
• The immune system is less than perfect.
• The level of lung damage more severe.
• Chronic inflammatory process in the airways.
• Pneumonia.
• Atelaktasis.
• Pneumothorax.
• Increase the risk of respiratory failure in patients.

Nursing Assessment  for Emphysema

1. Activity / Rest
Symptoms: Exhaustion, fatigue, malaise, inability to perform daily activities because of difficulty breathing, inability to sleep, need to sleep sitting up high, dyspnea at rest or in response to activity or exercise.
Symptoms: Fatigue, anxiety, insomnia, general weakness / loss of muscle mass.

2. Circulation
Symptoms: Swelling of the lower extremities.
Signs: Increased blood pressure, increased heart rate / severe tachycardia, dysrhythmias, distended neck veins, edema dependent, not associated with heart disease, heart sounds dim (which is associated with increased AP diameter of the chest), color of skin / mucous membranes: normal or gray / cyanosis, pallor may indicate anemia.

3. Foods / Liquids
Symptoms: Nausea / vomiting, poor appetite / anorexia (emphysema), inability to eat due to respiratory distress, permanent weight loss (emphysema), weight gain showed edema (bronchitis).
Signs: poor skin turgor, dependent edema, sweating, drop in body weight, decrease in muscle mass / fat subcutaneously (emphysema), abdominal Palpitations can cause hepatomegaly (bronchitis).

4. Hygiene
Symptoms: Decreased ability / enhancement needs help doing everyday activities.
Signs: Health less, body odor.

5. Respiratory
Symptoms: Shortness of breath (dyspnea hidden emergence as the prominent symptom of emphysema), especially at work, the weather or the recurrence of episodes of difficult airway (asthma), sense of chest pressure, inability to breathe (asthma)
"Air Hunger" chronic.
Shape settled with sputum production every day (especially when awake) for a minimum of 3 consecutive months each year at least 2 years. Sputum production (green, white and yellow) can be a lot of (chronic bronchitis)
Intermittent episodes of cough is usually not productive at an early stage can occur despite earning (emphysema)
A history of recurrent pneumonia: exposure to chemical pollution / respiratory irritants in the long term (eg, cigarette smoke) or dust / smoke (eg, abscess, or coal dust, sawdust)
The use of oxygen at night or continuously.

Signs: Respiratory: usually fast, slow, use of accessory muscles
Chest: hyperinflation with the elevation of the AP diameter, minimal movement of the diaphragm.
Breath sounds: may dim with expiratory wheezing (emphysema); spreads, soft or crackles, wheezing lungs throughout the area.
Percussion: hyperresonant the lung area
Color: pale with cyanotic lips and nail beds.

6. Security
Symptoms History of allergic reaction or are sensitive to substances / environmental factors, presence / recurrence of infection, redness / sweating (asthma).

7. Sexuality
Symptoms: Decreased libido.

8. Social interaction
Symptoms: The relationship of dependence, lack of support systems, improved inability / long illnesses.
Symptoms: Inability to / make maintaining respiratory sounds, physical mobility limitations, abnormalities with the family members.

9. Counseling / Learning
Symptoms: The use / abuse of drugs breathing, difficulty stopping smoking, regular alcohol use, failure to improve.



Nursing Diagnosis  for Emphysema

1. Impaired gas exchange related to ventilation-perfusion abnormalities secondary to hypoventilation.

2. Excess fluid volume related pulmonary edema.

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Clinical Manifestations and Diagnostic Examination of Cataract

Cataract is the name given to a clouding of the lens resulting in a reduction in visual acuity by a screen which is lowered in the eyes, like seeing the falls.

Type of cataract is the most common senile cataract and senile cataract is a degenerative process (deterioration). The changes coincided with presbyopia, but besides that it also becomes yellow and cloudy color, which would interfere with the refraction of light.

Although the so-called senile cataract but earlier changes can occur in middle age, at the age of 70 years most people have experienced changes in the lens even though it may only cause slight vision impairment.

Etiology of Cataract

• Aging (senile cataract).
• Trauma.
• Other eye diseases (uveitis).
• Systemic disease (diabetes).
• Congenital defect (a hereditary disorder as a result of prenatal viral infection, such as German Measles).

Clinical Manifestations of Cataract

Cataract is diagnosed primarily by subjective symptoms. Usually clients reported a decrease in visual acuity and glare as well as some degree of functional impairment caused by loss of vision earlier. Objective findings usually include condensation pearly gray on the pupil so that the retina would not appear with the ophthalmoscope. When the lens has become opaque, light will be open, be transmitted with a sharp focused image on the retina. The result is blurred vision or dim, glare is annoying eye shadow with distortion and hard look at night. Pupils are normally black will look gray or white.

Diagnostic Examination of Cataract

• Snellen eye chart / tele binocular eye machine: may be impaired by damage to the cornea, lens, aqueous / vitreous humor, refractive error, nervous system disease, vision to the retina.
• Field of vision: the decline may be due to the tumor mass, carotid, glaucoma.
• Tonograph: IOP (12-25 mmHg)
• Gonioscopy measurements from the point distinguishes open-angle glaucoma closed.
• Provocative test: determining the presence / type of glaucoma.
• Ophthalmoscopy: examines the internal structure of the ocular, optic disc atrophy, papilledema, bleeding.
• Complete blood, LED: indicates anemia systemic / infection.
• ECG, serum cholesterol, lipids.
• Glucose tolerance test: controls of DM.

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4 Types, Clinical Manifestations and Management of Thyroid Carcinoma

Thyroid carcinoma including malignant disease group with a relatively good prognosis, but clinical propagation are difficult to predict. Clients with Thyroid Ca experiencing high stress and anxiety. Nurses obtain basic data on the client based on the level of knowledge of the disease, coping skills and family relationships. The nurse encourages the client to express their fears and discuss the disease.

Histological

According to WHO, malignant epithelial tumors of the thyroid are divided into:

• Follicular carcinoma.
• Papillary carcinoma.
• Medullary carcinoma.
• Poorly differentiated carcinoma (anaplastic).
• Others.

According to Mc Kenzi (1971), there are 4 types of different thyroid carcinoma tissues used for day-to-day implementation, namely:

• Papillary thyroid carcinoma.
• Follicular thyroid carcinoma.
• Medullary thyroid carcinoma.
• Anaplastic thyroid carcinoma.

The initial clinical manifestations of thyroid carcinoma is a form of solitude and a nodule in the thyroid gland that is painless. Signs and symptoms depend on the presence or absence of additional metastases as well as the location of metastases (spread of cancer cells) itself.


1. Papillary carcinoma.
Is a type of thyroid cancer that is often found, much to the women or the age group above 40 years. Papillary carcinoma is a slow-growing tumor and can appear many years before spreading to regional lymph nodes. When the tumor is localized in the thyroid gland, the prognosis is good if the action is a partial or total thyroidectomy.

2. Follicular carcinoma.
There is approximately 25% of all existing thyroid carcinoma, especially regarding the age group above 50 years. Attack the blood vessels which then spread to the bone and lung tissue. Rarely spread to the lymph nodes but can be attached / stuck in the trachea, neck muscles, large blood vessels and skin, which then causes dyspnea and dysphagia. When a tumor on "The recurrent laryngeal Nerves", the client becomes hoarse voice. The prognosis is good if the metastases are still little, at the time of diagnosis set.

3. Medullary carcinoma.
Arising in the thyroid parafollicular tissue. The number of 5-10% of all thyroid carcinomas and generally the people aged over 50 years. Spread past the lymph nodes and invade surrounding structures. These tumors often occur and are part of the Multiple Endocrine Neoplasia (MEN) Type II is also part of the endocrine diseases, in which there is excessive secretion of calcitonin, ACTH, prostaglandins and serotonin.

4. Anaplastic carcinoma.
The tumor is growing quickly and outstanding aggressive. This type of cancer directly invading adjacent structures, which give rise to symptoms such as:

• Stridor (sound raspy / hoarse voice sounded loud breath)
• Hoarseness.
• Dysphagia.

The prognosis is bad and most of the clients died about 1 year after diagnosis set. Clients with a diagnosis of anaplastic carcinoma can be treated with palliative surgery, radiation and chemotherapy.


Clinical Manifestations of Thyroid Carcinoma

Clinical suspicion of thyroid carcinoma is based on the observation that was confirmed by pathological examination and suspicion are divided into high, medium and low. Which includes high index of suspicion is:

• History of multiple endocrine neoplasia in the family.
• Rapid tumor growth.
• Palpable hard nodules.
• Fixation surrounding area.
• Paralysis of the vocal cords.
• Enlargement of the regional lymph nodes.
• The presence of distant metastases.

Moderate suspicion:

• Age less than 20 years, or more than 60 years.
• History of neck radiation.
• Sex man with a solitary nodule.
• It is not clear fixation surrounding area.
• Diameter greater than 4 cm and cystic.

Low suspicion:

• Signs or symptoms outside / in addition to that mentioned above

Thyroid carcinoma clinically divided into classes, namely:

• Infra Thyroid.
• Neck glands Spleen metastasis.
• Extra Thyroid invasion.
• Far metastasis.

Clinical symptoms that can be found around the organs suppression, disruption and pain when swallowing, difficulty breathing, hoarseness, cervical lymphadenopathy and distant metastasis can occur. Most often to the lungs, bones and liver.

Management of Thyroid carcinoma

1. Surgery (thyroidectomy).
2. Radiation internal / external.
3. Chemotherapy.
4. Hormonal.
5. Others.

Evaluation

Made by examining fingerprints all over the body, combined with examination tiroiglobulin levels (Tg) serum periodically in the first 3-6 months. Tg is influenced by TSH and is likely to increase if there is residual thyroid gland. Tg levels less than 1 ng ml during the hormone was stopped, suggesting ablation therapy has been successful. Tg is considered as a sign of thyroid carcinoma is quite sensitive but not specific. The level of calcitonin for medullary carcinoma is an indication of metastasis.
Periodic evaluation is very important because thyroid carcinoma which has been declared successful ablation after 5-10 years turns malignant process could arise again. Recommended control 1 year for the first 5 years after total ablation declared successful, then once every 2 years.

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Nursing Diagnosis : Impaired Physical Mobility, Anxiety and Knowledge Deficit

Nursing Care Plan for Guillain-Barre Syndrome


1. Impaired Physical Mobility related to neuromuscular damage.

Goal / Outcomes:
Maintain body function with no complications (contractures, pressure sores).

Nursing Intervention :

Independent

1. Assess the strength of the motor / functional abilities using a scale of 0-5.
R /: Specifies the development / re-emergence of signs that hinder the achievement of goals / expectations of the patient.

2. Provide patient positioning lead to a sense of comfort.
R /: Reduce fatigue, enhance relaxation, reduce the risk of ischemia / damage to the skin.

3. Chock extremities and joints with pillows.
R /: Maintaining the limb in a position fisilogis, prevent contractures and loss of joint function.

4. Perform passive range of motion exercises.
R /: Stimulates circulation, improve muscle tone and increase joint mobilization.

Collaboration

5. Confirm with / refer to the physical therapy / occupational therapy.



2. Anxiety related to situational crisis.

Goal / Outcomes:
Appear relaxed and report anxiety is reduced to the level can be overcome.

Nursing Interventions:

Independent

1. Place the patient near the nurses' station, check the patient regularly.
R /: To provide assurance that immediate assistance can be done if the patient suddenly becomes not have the ability.

2. Provide primary care / nurse relationships are consistent.
R /: Improve mutual trust of patients and help to reduce anxiety.

3. Provide alternative forms of communication if necessary.
R /: Reduce feelings of helplessness and feelings of isolation.

4. Discuss the change in self-image, fear of losing the ability to settle, loss of function, death, problems regarding the need penyebuhan / repair.

Collaboration

5. Provide a brief description of the treatment, the patient's treatment plan, including the closest.
R. /: A good understanding can increase the need for patient cooperation activities and the involvement of patients and also the closest in care planning will be able to maintain some sense of control over themselves for life which will further enhance the self-esteem.



3. Knowledge Deficit related to less remembering, cognitive limitations.

Goal / Outcomes:
Patients know and understand about the disease.

Nursing Interventions:

Independent
1. Determine the patient's knowledge and ability to participate in the rehabilitation process.
R /: Influencing choice of interventions that will be done.

2. Review the patient's knowledge about the disease and its prognosis.
R /: The knowledge base is an important thing to make informed choices and participate in rehabilitation efforts.

3. Suggest to reveal what is in the natural, social, and increase independence.
R /: Increasing returns to normal and the development of his feelings on the situation.

4. Identify safety measures to find defeswit sensory-motor individually.
R /: Reduce the risk of injury / lower the actual risk of complications can still be prevented.

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Guillain-Barre Syndrome - Disturbed Sensory Perception

Disturbed Sensory Perception
related to:
changes in reception and transmission.

Goal /
Outcomes:
Reveals an awareness of deficits in sensory, mental or maintain general orientation and identify interventions to minimize damage / sensory complications.

Nursing Interventions:

Independent

1. Monitor neurological status on a periodic basis such as the ability to respond to simple commands and responds to pain stimulation.
R /: Development and reappearance of signs and symptoms may vary greatly. These developments are often quite quickly and possibly culminating in a few days / weeks. The healing process begins 2-4 weeks after the process ends and the progression of the disease and most slowly.

2. Provide a safe environment (bed barrier protection against thermal trauma).
R /: Loss of sensation and motor control patients make major concern of caregivers who must maintain a therapeutic environment and prevent trauma.

3. Provide an opportunity for resting on areas that are not susceptible to interference and provide other activities appropriate to the patient's ability boundaries.
R /: Reduce the excessive stimulus and can increase anxiety and minimize great coping skills.

4. Orient the patient returned to the environment as needed.
R /: Helps reduce anxiety and is particularly useful in case of visual impairment.

5. Provide appropriate sensory stimulation, encompass sound of soft music, television (news or a show).
R /: Patients feel isolated due to total paralysis and during the healing phase.

6. Suggest person closest to speak and give a touch of the patient and to maintain engagement with what is happening in the family.
R /: Helping people nearby, felt the mask on the patient's life (decrease feelings of helplessness / no expectations) and decrease patient anxiety during the breakup of the family.

Collaboration

7. Refer every related sources to aid speech therapy.
R /: Increases the healing process / minimize residual symptoms of neurological impairment.

8. Auxiliary perform plasmapheresis as needed.
R /: Handling the throw immunoglobulins, complement, vibrinogen and acute phase proteins that cause disease and respiratory depression in patients.

9. Provide medication as needed.

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Ineffective Breathing Pattern related to Guillain-Barre Syndrome

Nursing Care Plan for Guillain-Barre Syndrome

Nursing Diagnosis : Ineffective breathing pattern
related to:
weakness or paralysis of the respiratory muscles.

Goal / Outcomes:
Demonstrating adequate ventilation with no signs of respiratory distress, and effective breathing pattern.

Nursing Interventions:

Independent

1. Monitor the frequency, depth and symmetry of breathing. Note the increased work of breathing and skin color observations and mucous membranes.
R /: Increased respiratory distress indicate respiratory muscle fatigue and / or paralysis that may require support from mechanical ventilation.

2. Assess for changes in sensation, especially a decrease in the response.
R /: Decreased sensation often (though not always) lead to motor weakness.

3. Note the presence of respiratory fatigue during the talk if the patient is still able to speak.
R /: Is a good indicator of impaired respiratory function / decrease in lung capacity.

4. Auscultation of breath sounds, note the absence of sound or extra sound like crackles.
R /: The increase in airway resistance and accumulation of secretions or would interfere with the gas diffusion process and will lead to respiratory complications (such as pneumonia).

5. Elevate the head of your bed or put the patient in a sitting position leaning.
R /: Improving lung expansion and cough effort, decrease the work of breathing and limit the risk of aspiration of secretions.


Collaboration

6. Perform monitoring of blood gas analysis, pulse oximetry on a regular basis.
R /: Determine the effectiveness of the ventilation now and the need for / effectiveness of the intervention.

7. Perform to review the x-rays.
R /: The change is indicative of pulmonary congestion and or atelectasis.

8. Provide medication or help with the cleaning action of breathing, such as breathing exercises, chest percussion, fibrasi, and postural drainage.
R /: Improved ventilation and decrease atelectasis to mobilize secretions and improving lung expansion alveoili.

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Guillain-Barre Syndrome Care Plan Nursing

Definition of Guillain-Barre Syndrome

Guillain-Barre Syndrome is an autoimmune disease, in which the immunological process directly on the peripheral nervous system.

Guillain-Barre Syndrome (GBS) is an acute disorder of the nervous system, and diffuse the spinal roots and peripheral nerves and sometimes cranial nerve, which usually occurs after an infection.


Etiology of Guillain-Barre Syndrome

The etiology of Guillain-Barre Syndrome is still not yet known with certainty and is still a matter of debate. Scientists have theorized now is a disorder immunobiology, both in the primary immune response and immune-mediated process. Latent period between infection and symptoms polineuritis gives the notion that there is the possibility of a disorder caused by an allergic reaction in response to peripheral nerve. In many cases, the infection was not previously found, except sometimes the peripheral nerves and spinal ventral and dorsal fibers, there were also disturbances in the spinal cord and medulla oblongata.


Some state / diseases that precede and may have something to do with the occurrence of Guillain-Barre Syndrome, among others:

1. Viral or bacterial infection

Guillain-Barre Syndrome often associated with non-specific acute infection. The incidence of cases of Guillain-Barre syndrome associated with this infection approximately between 56% - 80%, ie 1 to 4 weeks before neurological symptoms arise such as upper respiratory infections or gastrointestinal infection. Acute infection associated with GBS:

a. Viruses: CMV, EBV, HIV, varicella-zoster virus, Vaccinia / smallpox, influenza, measles, mumps, rubella, hepatitis, Coxsackie, Echo.
b. Bacteria: Campylobacter, Jejeni, mycoplasma, Pneumonia, Typhoid, Borrelia B, paratyphoid, brucellosis, Chlamydia, Legionella, Listeria.

2. Vaccination.
3. Surgery, anesthesia.
4. Disease systematic, such as malignancy, systemic lupus erythematosus, thyroiditis, and Addison's disease.
5. Pregnancy or during childbirth.
6. Endocrine disorders.


Clinical Manifestations of Guillain-Barre Syndrome

1. The latent period

The time between infection occurs or circumstances preceding and current prodromal onset of neurological symptoms. The length of the latency period ranging from one to 28 days, an average of 9 days. At this latency period no clinical symptoms arise.

2. Symptoms Clinical

a. Paralysis
The main clinical manifestation is paralysis of the muscles of the lower extremity motor neurone type of limb muscles, body and face sometimes. In most patients, paralysis of both lower extremities begins later spread asenderen to the body, upper limbs and cranial nerves. Sometimes it can also be subject to the four limbs simultaneously, and then spreads to the body and cranial nerves. Paralysis of these muscles symmetrical and followed by hyporeflexia or areflexia. Usually the degree of paralysis of the muscles of the proximal portion of the distal portion is heavier, but it can also be as demanding, or more severe distal part of the proximal portion.

b. Impaired sensibility
Paresthesia is usually more pronounced in the distal extremities, face also may be subject to circumoral distribution. Objective sensory deficit is usually minimal and often with patterns of distribution such as socks and gloves. Exteroceptive sensibility is more commonly known than the proprioceptive sensibility. Muscle pain such as pain often encountered after a physical activity.

c. cranial nerves
Cranial nerves are most commonly known is N.VII. Paralysis of facial muscles often begin on one side but then soon became bilateral, so that the weight could be found between the two sides. All cranial nerves may be subject except N. I and N.VIII. Diplopia could occur from involvement N.IV or N.III. When exposed N.IX and N. X will cause a swallowing difficulty, dysphonia, and in severe cases cause respiratory failure due to paralysis of n. laryngeal.

d. Impaired autonomic function
Impaired autonomic function observed in 25% of patients with GBS. The disorder in the form of sinus tachycardia, sinus bradycardia, or more rarely, so red face (facial flushing), hypertension or hypotension fluctuating, episodic loss of sweating or profuse diaphoresis. Urinary retention or urinary incontinence are rare. This rare autonomic disorder that lasts more than one or two weeks.

e. Respiratory failure
Respiratory failure is a major complication that can be fatal if not treated properly. Respiratory failure is caused by paralysis of the diaphragm and the paralysis of the respiratory muscles, which is found in 10-33 percent of patients.

f. Papilledema
Sometimes encountered papilledema, the cause is not known with certainty. Allegedly due to elevation of the protein content in muscles that cause blockage of fluid arachoidales villi that absorption of cerebrospinal fluid is reduced.


Nursing Diagnosis for Guillain-Barre Syndrome

1. Ineffective breathing pattern
related to:
weakness or paralysis of the respiratory muscles.

2. Disturbed Sensory perception
related to:
changes in reception and transmission.

3. Ineffective Tissue perfusion
related to:
autonomic nervous system dysfunction that causes vascular buildup with decreased venous return.

4. Impaired physical mobility
related to:
neuromuscular damage.

5. Imbalanced Nutrition: less than body requirements
related to:
damage affecting neuromuscular reflex swallowing and GI function.

6. Anxiety
related to:
situational crisis.

7. Pain Acute / Chronic
related to:
neuromuscular damage (paresthesias, disestesia)

8. Knowledge Deficit
related to:
less remembering, cognitive limitations.

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Nursing Concept of Personality Disorders

General Concept of Personality Disorders

1. Personality disorder primarily involves problems with interpersonal relationships.
2. Personality disorders are generally chronic, pervasive (affecting all areas of the client's life), and maladaptive (eg, personality disorders cause significant difficulty in life, work and family life).
3. Personality disorder involves a pattern of excessive or oddly normal personality.
4. Personality disorders can occur together with other severe psychiatric problems.
5. Personality disorders may be difficult to be treated or diagnosed.

Common Symptoms of Personality Disorders

1. Suspicious or do not believe.
2. Rigid thinking.
3. Distortion of reality.
4. Projection.
5. Afec limited or excessive.
6. Isolation.
7. Unstable interpersonal ties.
8. Limited or excesses of moral development.
9. Self-care deficit.
10. Somatic symptoms.
11. Thinking delusions.
12. Bad identity or excesses sense of self importance.
13. Potentially damaging to self or others.

Type of Pervasive Personality Disorder


Group A

1. Paranoid Personality Disorder: do not believe the total on others begins in young adulthood, indicated by at least four of the following conditions:

• Suspiciously, without cause, that people exploit or cheat.
• Busy with vague doubts about the loyalty or honesty of a friend or colleague.
• Finding hidden harassment or threatening meaning of a comment or trivial events.
• Always hurt or complain.
• Attacks (not visible to others) on the character or reputation of a person, followed by a fast reaction of anger or counterattack.
• Suspicious relapse.

2. Schizoid Personality Disorder: Patterns of separation settling of social relations and also the limited range of emotional expression in interpersonal relationships begins in young adulthood, indicated by at least four of the following symptoms:

• Lack of desire or inability to enjoy intimate relationships, including with his own family.
• The choices are almost always exclusive to a solitary activity.
• Few, if any, attention to sexual experience with another person.
• Experience the pleasure of little, if any, activity.
• Lack of good friends.
• Indifferent to praise or criticism.
• Cold emotion and flat affect.

3. Schizotypal Personality Disorder: Patterns of social and interpersonal deficits persist (acute discomfort, and reduced capacity for close relationships, cognitive or perceptual distortions and behavioral egocentricity) begins in young adulthood, indicated by at least five of the following symptoms:

• Ideas of reference (excluding delusions of reference).
• Odd beliefs or magical thinking that influences behavior.
• Unusual perceptual experience (Illusions body).
• Thinking and talking weird (not clear, circumstantial, metaphorical, excessive elaboration, stereotyped / repetitive)
• Suspicious or paranoid thinking).
• Afek Improper or restricted.
• Behavior or strange or eccentric appearance.
• Lack of good friends.
• Of excessive social anxiety that does not diminish with familiarity and usually including paranoid thoughts.

Group B


1. Antisocial Personality Disorder

• Evidence of conduct disorder before the age of 15 on the client at least 18 years old.
• The pattern is not settled appreciate and violate the rights of others since age 15, as indicated by three of the following conditions:

• Failed to comply with social norms or law-abiding behavior.
• Irritability or aggressiveness.
• Is not responsible for the employment history and financial obligations.
• Impulsive and fail to plan ahead.
• Traitor.
• Not respect the safety of self and others.
• Lack of feeling regret.

2. Borderline Personality Disorder: patterns persist instability in interpersonal relationships, self-image, affective, and impulse control begins in young adulthood, indicated by:

• Enterprises like crazy / hysterical to avoid waiver (not including suicide attempts and acts of self-harm).
• Unstable personal relationships and stiff.
• Settled identity disorder.
• Impulsive behavior, reckless, at least 2 of the following areas: spending, sex, substance abuse, driving, overeating.
• Behavior or signs or threats of suicide or self-harm relapse / recurrence.
• Manifestation of mood reactivity, usually for short periods rarely exceed a few days.
• Chronic feelings of emptiness and boredom.
• Angry stiff, Improper, lack of control of anger.
• Stress-related paranoid thoughts, temporary or disosiataif severe symptoms.

3. Histrionic Personality Disorder: patterns of emotional and behavioral excesses settled attention-seeking, beginning in young adulthood is indicated by at least 5 of the following symptoms:

• Feel uncomfortable when not the center of attention.
• Behavior or sexual seducing unnatural appearance.
• Emotional instability.
• Very concerned (excessive) to the physical appearance, using it to draw attention to themselves.
• Talk excessively impressionistic style and lack of detail.
• Self-dramatization, exaggerated expression of emotions and theatrical.
• Forcing.
• The mistaken belief that the relationship with other people is more intimate than a reality.

4. Narcissistic Personality Disorder: patterns of settling pretense, need for admiration and lack of empathy, beginning in young adulthood is indicated by five of the following symptoms:

• Strong sense of self importance.
• Preoccupied with thoughts of success, beauty, intelligence, power and infinite love.
• Convinced that he superrior (great) and just want to connect with people or institutions that great.
• Need admired and considered excessive.
• Strong feelings that are entitled to preferential treatment / special.
• Exploit others.
• Lack of empathy.
• Envious of others or believes others envy him.

Group C

1. Shy Personality Disorder: patterns of social barriers persist, and hypersensitive to criticism, beginning in adulthood, indicated by at least four of the following symptoms:

• Avoid work activities including significant interpersonal contact.
• Not willing to risk engaging in intercourse without certainty of success to be liked.
• Limiting intimate relationship.
• Busy with the fear of being rejected or criticized in social situations.
• Shame in a new relationship.
• Sure that could not socially, personally or lower unattractive to others.
• Not willing to risk personal or engage in new activities.

2. Dependency Personality Disorder: The need for excessive settling and treated / untreated, leads to submissive and dependent behavior and fear of separation. Starting in young adults is indicated by at least 5 of the following symptoms:

• Inability to make decisions every day without excessive advice from others.
• Need someone else to take over responsibility in life.
• Reluctant to disagree with others because of fear of rejection.
• Difficult to start a project and do everything yourself.
• Highly sought to gain emotional support from others (voluntary does not unpleasant).
• Feel uncomfortable or no expectations when alone.
• Trying to find a new dependency relationship when a close relationship ends.
• Busy with fear sendirri left to care for themselves.

3. Obsessive-Compulsive Personality Disorder: Patterns settled busy with regularity, perfection and mental and interpersonal control will cost flexibility, openness and efficiency, beginning in young adulthood is indicated by at least four of the following symptoms:

• Busy on the details, rules, lists, scheduling organization, causing inability to focus on the main point of an activity.
• Perfectionists who disrupt the completion of a task.
• Excessive loyal towards work and productivity by eliminating the activity fun and friendship.
• Very careful, meticulous and unusual klentur about morality, ethics and values​​.
• The inability to throw useless things.
• Reluctant to delegate tasks except the task will be done in accordance with the doing.
• Stingy with money.
• Rigid and stubborn.

4. Agresig-Passive Personality Disorder

• Registered as a non-specific personality disorder who have behavior more than 1 personality disorder but no full criteria for a single personality disorder.
• Common symptoms of passive aggressive behavior affect social interaction and work.
• Procrastination / Likes to procrastinate.
• Failed to perform a task or a bad job when do not want doing.
• Will hurt suggestions on how to improve performance.
• Failure to do part of the job fair yag.
• Excessive deride and criticize superiors.
• Improper claims that her demands and irritable and arguing when asked to perform a task.

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Nursing Management for Paranoid Personality Disorder

According to JP Chaplin, PhD. , Paranoid is a feature that psikotic disorder characterized by systematic delusions or delusions with little deterioration. This tends to settle and strong enough influence and incapacity.

Paranoid personality:
A personality is characterized by an attitude of suspicion, is very sensitive in the absence of deterioration or delusions.

Paranoid schizophrenia:
One type of schizophrenia characterized by delusions or symptoms highly suspicious attitude. This is due to dysfunction disorder thinking, hallucinations and deterioration.

According to James C. Coleman, Paranoia A characteristic of psychosis is characterized by systematic delusions.

Paranoid Personality:
Individuals who show behavioral symptoms such as defense mencahnism projections, suspicious, jealous, very jealous and stubborn.

Paranoid Schizophrenia:
One type of schizophrenia is characterized by delusions and hallucinations are usually quite strong.

Currently there are 2 types of paranoid psychosis belonging paranoid disorders, namely:

1. Paranoia, where the delusiyang develop slowly and then becomes complicated, logical and systematic and it is centered on feel persecuted delusions or delusions of grandeur. Despite the presence of delusions, the patient's personality is still intact, there are no serious disorganization and without hallucinations.

2. Paranoid state, a change in the paranoid and delusional thinking becomes ligis and emergence characteristics of paranoia, although it has not shown any strange behavior or deterioration such as that found in the case of paranoid schizophrenia. This condition is usually associated with strong stress and mortality may also be due to the phenomenon. Paranoid states often color the clinical picture of the type of other pathological disorders.

However, our main interest is currently focused on paranoia. Paranoia is relatively less common in patients treated in psychiatric hospitals, but this may occur due to mis-identification of mental disorders. Many of the inventor / inventors, teachers, business executives, reformers fanatical, jealous spouse, eccentric people who study a particular teachings are included in this category. However, they are uniquely able to maintain its existence in the society. In some cases some of the women who developed into a very dangerous man.


Clinical Manifestation of Paranoia

Individuals who experience paranoia feel alone, neglected, spied upon, and other false perception of the threat from 'the enemy.' Delusions are usually centered on one thing, for example concerning the financial problems, labor, ill trustworthy partner or other life issues . People who have failed in work will develop suspiciously like someone else cembutu on his performance so want to drop it.

A paranoia has a particular reason why they are suspicious and do not want to receive another reason which is more correct. Because of the suspicion he may conduct interrogations of those deemed enemies.

Many of these paronoia has delusions where he was a superior and has the unique capability. Sometimes they feel a mandate or revelation to run a sacred mission, social reforms, and modifiers. The paranoiac religious develop the confidence that he got a message from God to save people and do the sermons even invite does holy war.

In connection with the paranoiac delusions experienced can be performed with very perfect, speaks eloquently and has impressed emosian mature. Hallucinations and characterize other disorders rarely found in this paranoiac. They seek to justify the logical ways in order to be believed. In this case very difficult to distinguish where the facts or just images. They are working on making the people around him believe what he says. They fail to see the facts other than what they believe and are less able to prove his faith, kecurigaanya and they become communicative when asked about these delusions.

However this is not always harmful paranoic, but they still have a chance to do something that is detrimental to the perceived enemy.


Stages of thinking that led to paranoia:

1. Suspiciousness / Suspicious - people become distrustful of others, fear of hurt and be very alert.
2. Protective Thinking - selectively reviewing the actions of others and see it suspicious and start blaming others for his failure.
3. Hostility - very sensitive to perceived injustice is not true though, it responded in anger and hostility and suspicion is further increased.
4. Paranoid Illumination / Growing Paranoid - suspicious attitude has become part of him and he felt the presence of something strange, but he he has been immersed in a situation such suspicion.
5. Delusions - feel persecuted or absence of delusions of greatness, but he developed a logical reason and to develop actions that can be understood by others.



Treatment for Paranoid Personality Disorder

In the early stages of paranoia, corporately and individually handling is still effective, especially if the patient has a consciousness to obtain the help of professionalism.

Behavioral therapy techniques show promise such things, paranoid ideas arise due to various combinations of things that are not fun, the various factors of change in a person's life situation further strengthens maladaptifnya behavior and develop into a powerful way to resolve the problem.

Once settled delusional system, the handling will be very difficult. Usually difficult to communicate with paranoiac to tackle the problem in a way that is rational. In this situation the patient is reluctant to consult, but they are trying to find justification and understanding of other people on their mistakes.

At the time of initial identification of psychosis with schizophrenia and paranoia, it was agreed that the clinical manifestations of this case must be distinguished from neurosis or psychosomatic disorders. The hallmark of schizophrenia clearly a failure of understanding / contact with reality and personality disorganization occurs as disturbances in the function of thinking, affective / feeling or behavior problems.

Identification of most types such as acute schizophrenia, paranoid, catatonic, hebephrenic and simple show clinical differences for each type. Various factors cause remains elusive why it can thrive. However experts notice any significant role of genetic factors that cause schizophrenia. Perhaps because neuropshysiological or biochemical changes that disrupt the normal functioning of the brain, including the failure here is in the selection mechanism. The exact cause of these changes must be ascertained to determine whether due to genetic factors or because of a mental disorder. However, it should also be noted that a significant cause of psiikologis other. Besides that psychosocial factors play an important role to consider such innovative pula.Penanganan chemotherapy, psychosocial therapy, post-treatment program would make people better condition.

Paranoid disorder usually do not experience severe personality disorganization compared to other types of psychosis, but they are very resistant / reject any given therapeutic action.

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Treatment for Victims of Physical Abuse and Violence

Common actions for victims of abuse

1. Give first aid as needed.
2. When violence or abuse is very prominent, separate the victims from the perpetrators.
3. Report any abuse in child protection services and the elderly, as required by law.
4. In the case of the persecution of women, reporting is required if the injury was caused by a gun, knife or other weapon.
5. If sexual abuse is suspected, follow the laws and institutional procedures for collecting and storing evidence admitted in evidence a series of procedures.
6. Ensure that victims receive sensitive care and compassionate.
7. Give full support to the victims not to tolerate abuse.
8. Listen with empathy explanation about the victims of persecution now and past.
9. Record all injuries incurred and treatment rendered.
10. In collaboration with a team approach, including inter-agency referral initiate and participate in case conferences.

Action for victims of physical abuse and violence on children

1. Make sure the child is comfortable with making the right introductions and do not touch a child without permission when conducting interviews.
2. Use play activities, including drawing, to encourage children to tell or express feelings, for children who are reluctant or unable to express the trauma they experienced.
3. Describe all tests and medical procedures in terms that can be understood, before the procedure is executed.
4. Improve the child's relationship with parents; nurses can not be a substitute for separating parents with the child's biological parents.

Action for victims of physical abuse and violence on women

1. Communicate acceptance, warm and non-judgmental; do not deliver though indirectly that he is guilty of not leaving the abusive environment.
2. Improve the safety and awareness of his right to be free from persecution.
3. Discuss the various options available, including shelter, legal protection to report abuse and seek protection from persecution through the courts.
4. Respect the victim's decision, including the decision to return to the abusive situation or the decision not to report the abuse.
5. Help her to make plans to ensure safety, including home and auto hide duplicates; asking neighbors to report to the police when violence began to occur; store documents such as birth certificates, bank account numbers, social security numbers, and rental receipts or purchases of goods available; maintains a list of telephone numbers of emergency shelter, legal aid, police, counselors and support groups.

Action for victims of physical abuse and violence on elderly

1. Give it time and patience to be able to make the elderly discuss the situation.
2. Respect the dignity of the client and should not be judge.
3. Discuss the options available to ensure safety, such as temporary hospitalization, placement in a home that is safe and protective orders from the court.
4. Provide a list of resources and support services, including adult protective services, legal aid, victim resource agencies, local units of elderly and 24-hour hotline number for the issue of persecution of the elderly.

Measures for Post Traumatic Stress Disorder

1. Use the implementation associated with anxiety (eg, relaxation techniques, encourage expression of feelings, limiting caffeine and nicotine.
2. Validation on the client that they experienced traumatic events cause enormous stress.
3. Help clients disclose all aspects of the traumatic event, including thoughts and feelings.
4. Teach the client about coping strategies to manage anxiety symptoms that accompany memories of trauma.
5. Encourage clients to participate in a support group or self-help groups.
6. Refer clients to alcoholic anonymous or narcotics anonymous if alcohol or drug abuse problem for clients.

Action for abuses committed against

1. When actors threatening persecution or being under the influence of drugs or alcohol, the nurse should call security or police to ensure the safety of themselves and others.
2. Notify molesters on duty to report maltreatment to the designated agency.
3. Get help from a team of experienced health workers (eg, clinical nurse specialists, social workers, representatives of protection agencies, mental health crisis workers) to start the intervention.
4. In situations of child abuse, the nurse can be helpful with regard parents as clients as victims of abuse and their children.
5. If persecution is recognized by the culprit, encourage him to be responsible for violent behavior does.
6. Communicate belief that violent behavior can be controlled and that there are other functions that could be more appropriate and possible.
7. Advise and refer perpetrators of the abuses to the community resource agencies, such as mental health services, parent education courses, self-help groups, and nursing home.

Action for families

1. Teach the family about the importance of individual responsibility for the behavior of each.
2. Teach the family to recognize stressful situations.
3. Teach the family to develop strategies for problem solving or coping strategies.
4. Teach families about effective parenting skills.
5. Teach the family to use community resources and professional assistance to improve family functioning.

Action for community

1. Seeks to reduce violence-related conditions (eg, poverty, inadequate housing, dysfunction attitudes towards violence, substance abuse). For example: joining volunteer organizations, lobby with local officials.
2. Trying to develop and maintain a family of resources (eg, child care services, nursing homes, educational programs, support groups)
3. Support and enhance the legal and legislative efforts to eliminate domestic violence.

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Sample of NCP Basic Human Needs: Personal Hygiene

ASSESSMENT

1. Client Identification

• Name:
• Address:
• Age:
• Gender:
• Level of education:

2. Health History

• Assess individual patterns of daily hygiene.
• Assess the factors that influence individual hygiene include:
• Culture: for example, the myth that being sick should not shower because it will aggravate the disease.
• Socio-economic status: to fulfill that adequate facilities and infrastructure.
• Religion: beliefs affect individuals within executing daily habits.
• The level of knowledge or the development of the individual to health.
• Health Status: will affect an individual's ability to perform self-care.
• Habit: the habit of using certain products in self-care.
• Physical disability:

3. Physical Assessment

• Hair: look dull? is there a loss?
• Scalp: dandruff, bald and signs of inflammation (redness, swelling)
• Eyes: observe signs of jaundice, pale conjunctiva, discharge on the eyelids, redness and itching of the eyelids.
• Nose: assess for sinusitis, nasal bleeding, signs of a cold that does not go away, the signs of allergy.
• Mouth: observe the presence of lesions, mouth sores, dry or chapped.
• Teeth: observe signs of tartar, caries, cracked teeth, incomplete and false teeth.
• Ear: observe the presence of cerumen, lesions, infections, changes in hearing.
• Skin: observe the texture, turgor and moisture and skin hygiene: Strie, wrinkled skin, lesions, pruritus.
• Hands and feet nails: nail observe cleanliness.
• Genetalia: observe cleanliness.

Etiology

1. Physical fatigue
2. Impairment of consciousness
3. Factors predisposing

• Developments: Family too protect and pamper clients.
• Biological: chronic disease.
• Ability reality down: Mental disorders.
• Social: less support and self-care skills training environment.

4. Factors precipitation

• Less / decreased motivation.
• Impairment in cognition or perceptual.
• Anxious.

5. Partial or total paralysis, secondary to (specify)
6. Coma
7. Visually impaired secondary to (specify)
8. Extremity malfunction
9. External equipment (casts, splints, advocates, IV)
10. Fatigue and post-operative pain
11. Pain


Signs and Symptoms

1. Subjective data

• Patients feels weak.
• Lazy to move.
• Feel powerless.

2. Objective data

• Filthy hair, unkempt.
• Bodies and clothes dirty and smelly.
• Mouth and teeth dirty with stink.
• Skin dull and dirty.
• Long nails and unkempt.
• Untidy appearance.

Psychologically: Lazy, no initiative, self Attractive, self-isolation, Feeling helpless, low self-esteem and feel humiliated.

Social: less interaction, less activity, not able to behave according to normal, eating irregular way, urinate and defecate in any place, brush your teeth and shower are not able to be independent.


Nursing Diagnosis

1. Self-Care Deficit: Bathing / hygiene (Less self care (bathing) is an impaired ability to perform activities of bathing / personal hygiene). relate to:

2. Self-Care Deficit: Wearing apparel / ornate.
Self-Care Deficit (wearing clothes) is an impaired ability to wear their own clothes and dress up activities.

3. Self-Care Deficit: Eat
Self-Care Deficit (eating) is an impaired ability to demonstrate the activity of eating.

4. Self-Care Deficit: toileting
Self-Care Deficit (toileting) is an impaired ability to perform or complete the toileting activity itself. (Nurjannah: 2004, 79).

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3 Nursing Interventions for Spina Bifida

Spina bifida is an anomaly in the formation of the spine, which is a defect in the closure of the spinal canal. This usually occurs in the fourth week of the embryonic period. This closure is usually a disorder of the posterior spinous processes and laminae; very rarely defects occur in the anterior portion. There is largest at the lumbar spine or lumbosacral.

Spina bifida is a general term for NTD (Neural Tube Defects) that the spinal area. The disorder is a separation of arcus vertebrae and nerve tissue underneath may or may not. (T.W.Sadler, 2010)


Etiology

1. Genetic
2. Hyperthermia, lack of folic acid and hypervitaminosis A.
3. Happen again high risk in children of mothers who had given birth with Spina bifida abnormality (TWSadler, 2010)


Pathophysiology

Pathophysiology of spina bifida easily understood when linked to measures of normal development of the nervous system. At approximately 20 days of gestation determined pressure neural groove. Sightings in the dorsal ectoderm and embryonic. During pregnancy week 4 seemed to deepen the groove quickly, leaving the boundaries of growing to the side, then the axis behind the forming neural tube. Neural tube formation begins in the cervical region near the center of the embryo and advanced caudally and cephalically direction until the end of the 4th week of pregnancy, on the front and rear neuropores closed. The main damage to neural tube defects can be due to neural tube closure.

In pregnancy week 16 and 18 formed serum alpha fetoprotein (AFP) in pregnancy so that an increase in fluid cerebro spinal AFP. Such improvements may result in leakage of cerebro spinal fluid into the amniotic fluid, then the fluid mixes with amniotic fluid AFP forming alpha-1-globulin that affect the process of cell division to be imperfect. Hence the closure of the vertebral canal defect that causes incomplete congenital failure of fusion of the dorsal folds are common in neural tube defects and exophthalmos (John Rendle, 1994).

Clinical manifestations

1. Spina bifida occulta may be asymptomatic / relating to:
a. Hair growth along the spine
b. The bottom middle indentation, usually diarea lumbosacral
c. Abnormalities of gait / foot
d. Control / poor bladder

2. Meningocele may be asymptomatic / relating to:
a. Pouch-like protrusion of the meninges and css from the back
b. Club foot
c. Gait disturbance
d. Urinary Incontinence overdo

3. Myelomeningocele relates to:
a. Protrusion of the meninges, css and spinal cord
b. Neurological deficits as high and below the exposure


Nursing Interventions and Nursing Diagnosis for Spina Bifida


1. Urinary incontinence related to visceral paralysis

Expected outcomes / Goal:
expected: the client urination normal in number and frequency.

intervention:
a. Assess the level of incontinence and voiding patterns.
b. Provide care to the client's skin wet with urine (wipe warm water then wipe dry and give the powder).
c. Instruct the client's mother to check diapers often, if wet immediately replaced.
d. Collaboration with the medical team in giving drugs (eg anticholinergics).


2. Risk for injury related to spastic paralysis

Expected Outcomes / Goal:
expected: the patient's parents know about the things that lead to injury.

intervention:
a. Teach or suggest to parents to prevent children from dangerous objects that could cause injury.
b. Demonstrate to parents that some games do not cause injury.
c. Provide health education to parents regarding drugs or handling of the first case of injury in children.
d. Provide support to children in order not to feel inferior to his condition.


3. Impaired Physical Mobility r / t the motor paralysis

Objectives:
the client is able to carry out physical activity according to ability.

Outcomes: the client can participate in an exercise program, do not happen joint contractures, increased muscle strength. The client indicates action to improve mobility.

intervention:
a. Assess existing mobility and observation of an increase in damage. Assess motor function regularly.
b. Change the client's position every 2 hours.
c. Teach the client to perform active motion exercises of the extremities that are not sick.
d. Perform passive motion on the affected extremity.
e. Maintain a 90-degree joints of the foot board.
f. Inspection of the distal part of the skin every day. Monitor the skin and mucous membranes irritation, redness or blisters.
g. Help clients perform ROM exercises. Self-care as tolerated.
h. Collaboration with physiotherapist for physical exercise.

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Care Plan and Nursing Diagnosis for Spina Bifida

Nursing Assessment for Spina Bifida

Subjective and objective data collection on the nervous system disorders, in connection with spina bifida complications depends on other vital organs. Nursing assessment of spina bifida include anamnesis, medical history, physical examination, diagnostic studies, and psychosocial assessment.

1. Anamnesis

The identity of clients includes name, age, gender, education, address, occupation, religion, nationality, date and time of hospital admission, registration number, health insurance, medical diagnostics.

The main complaint is often the reason for a client to ask for help health is the presence of signs and symptoms similar to spinal cord tumors and neurological deficits. Complaints of lumbosacral lipoma on an important sign of spina bifida.


2. History of the disease at this time

Complaints of neurological deficits can manifest as impaired motor (motor paralysis of the lower limbs) and the inferior extremity sensory and / or disorders of the bladder and the sphincter of the stomach. Complaints of unilateral foot deformity and leg muscle weakness is the most common defect. Small feet can occur trophic ulcers and pes cavus. This condition may be accompanied by sensory deficits, especially in the distribution of L3 and S1. Complaints bladder sphincter disorders are found in 25% of infants with neurological involvement, lead to urinary incontinence, urinary dripping, and recurrent urinary tract infections. Usually accompanied by the anal sphincter weakness and sensory disturbance perianal area. Neurological disorders can gradually deteriorate, especially during adolescence mass growth.


3. History of previous illness

Assessment that need to be asked include a history of the growth and development of children, history meningomyelocele ever experienced before, a history of infection subarachnoid space (sometimes chronic or recurrent meningitis), a history of spinal cord tumors, poliomyelitis, spinal developmental disabilities, such as diastematomyelia and foot deformities.


4. Assessment of psychosocial

Assessment of coping mechanisms used and the client's family (parents) to assess the response to illness and changing roles in the family and society as well as responses or influence in their daily lives either in the family or in society. Are there impacts on the client and the parents that raised fears of disability, anxiety, a sense of inability to perform activities optimally.


5. Physical examination

After making the history that led to the complaint the client physical examination is very useful to support the assessment of data from history. Physical examination should be performed by the system (B1-B6) with a focus on examining physical examination B3 (brain) directed and connected with complaints from clients.

a. The general state
In case of spina bifida generally experience loss of consciousness (GCS less than 15), especially if it occurs widely neurological deficits and changes in vital signs.

b. B1 (Breathing)
Changes in the respiratory system associated with inactivity weight. In some circumstances, the results of the physical examination found no abnormalities.

c. B 2 (Blood)
Bradycardia is a sign of changes in brain tissue perfusion. Looked pale skin indicates a decrease in hemoglobin levels in the blood. Hypotension indicates a change in tissue perfusion and early signs of a shock.

d. B3 (Brain)
Spina bifida causes a variety of neurological deficit was primarily due to the effect of increased intracranial pressure. Assessment of B3 (Brain) is a focus and a more complete examination than assessments on other systems.

e. B4 (Bladder)
In the advanced stages of spina bifida, a client may experience urinary incontinence due to confusion and inability to use the urinary system due to damage motor and postural control. Sometimes the external urinary sphincter control is lost or diminished. During this period, intermittent catheterization performed with sterile technique. Urinary incontinence that persists showed extensive neurological damage.

f. B5 (Bowel)
The presence of fecal incontinence that continues to show widespread neurological damage. Bowel examination to assess the presence or absence of bowel sounds and the quality should be assessed prior to abdominal palpation. Bowel sounds are decreased or lost may occur in paralytic ileus and peritonitis.

g. B6 (Bone)
The presence of foot deformity is one important sign of spina bifida. The most common motor dysfunction is the weakness of the lower extremities. To assess the integrity of the skin lesions and sores. Be difficult to move because of weakness, sensory loss or spastic paralysis and fatigue cause problems on the pattern of activity and rest.


6. Diagnostic tests

Spine x-rays to identify any defect in the spine, usually occurs in the posterior arch of the vertebra in the spine midline amount varies. The presence of spinal dyspropism or widening of the spine is a typical sign of radiology at the lumbar (Perkin, 1999).



Nursing Diagnosis for Spina Bifida

1. Urinary incontinence r / t paralysis visceral

2. Risk for injury r / t spastic paralysis

3. Impaired Physical Mobility r / t motor paralysis

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Acute Pain and Anxiety - NCP for Intestinal Obstruction

Intestinal obstruction (ileus) is a disorder passage of intestinal contents due to blockage resulting in accumulation of fluid and air in the proximal part of the blockage. As a result of the blockage, an increase in intraluminal pressure and intestinal disturbances resorption and increased intestinal secretion. Combined with vomiting as a result of an obstruction or reflux due to regurgitation of stomach full of lead to dehydration, febrile and shock. Obstruction ileus is also an urgency in abdominal surgery is often encountered, is 60-70% of all cases of acute abdomen that is not acute appendicitis. Obstructive ileus also called mechanical ileus.

Based on the mechanism of the obstruction, then the mechanical obstruction can be divided into:
A. Obstruction of the bowel lumen (Intra luminaire), namely:

• Polypoid tumor.
• Intussusception.
• Gallstone ileus.
• Feces, meconium bezoar (infants).

B. Abnormalities of the intestinal wall (Intramural), mostly congenital in infants:

• Atresia.
• Stenosis.
• Duplication.

In adult patients:

• Neoplasms.
• Inflammation.
• Crohn's disease.
• Post radiation.
• Gut connection.

C. Abnormalities outside the colon (Luminaire)

• Adhesion.
• External hernia.
• Neoplasms.
• Abscess.

Clinical Manifestations : Small Bowel Obstruction

Complaints arising in patients with intestinal obstruction is typical:

• Abdominal pain, vomiting, obstipation, abdominal distention, no flatus and bowel movement.
• These painful cramps can be repeated at intervals of 4-5 minutes on intestinal obstruction proximal part. In intestinal obstruction distal part of the frequency increases rarely.
• After a long obstructed the cramping pain will diminish or disappear because of intestinal distention or movement will be reduced after the strangulation with peritonitis, abdominal pain became severe and continuous.
• At the proximal intestinal obstruction occurred profuse vomiting with mild distension.
• At the distal intestinal obstruction, vomiting rarely with vomit the contents of feces, but more severe distension.
• Increased abdominal circle occurs because of the removal of liquids and gases within the lumen of the intestine due to obstruction in the distal part of the intestine and colon, or paralytic ileus.
• In the early stages, normal vital signs. Along with the loss of fluid and electrolytes, dehydration will occur with the clinical manifestations of tachycardia and postural hypotension. The body temperature is usually normal but sometimes it can be increased.
• Physical examination found the presence of fever, tachycardia, hypotension and severe dehydration symptoms.
• Fever indicates obstruction strangulate. On examination the abdomen appeared distended abdomen obtained and increased peristaltic (sounds borborygmi). In advanced stages where the obstruction continues, peristaltic will weaken and disappear. The presence of feces mixed with blood on rectal examination can toucher suspected malignancy and intussusception.

Nursing Diagnosis : Acute Pain related to an increase in intestinal intraluminal pressure.

characterized by: grimacing expression, complained of feeling pain in the abdominal area.

Goal: expected pain is resolved or controlled.

Outcomes:

• Revealed a decrease in discomfort.
• Stating pain at a tolerable level, indicating relaxed.
• Showed pain control measures.

Intervention:

1) Assess pain with PQRST technique.
Rationale: Monitor and provide an overview of the characteristics of the client and the pain indicators in subsequent interventions.

2) Maintain bed rest in a comfortable position.
Rationale: Bed rest reduces energy use and help control pain and reduce muscle contractions.

3) Teach relaxation or distraction techniques such as listening to music or watching tv.
Rational: to help clients feel more relaxed until the pain can be reduced.

4) Collaboration of analgetic drugs.
Rational: analgesic drugs will block the pain receptors so that pain can not be perceived.



Nursing Diagnosis : Anxiety related to change in health status.

characterized by: increasing the pain of powerlessness, expressed concern.

Goal: expected to decrease anxiety.

Outcomes:

The client will use relaxation techniques to relieve anxiety.

Intervention:
1) Assess the client's level of anxiety.
Rationale: Knowing the coping abilities of individuals.

2) Take time to listen to express anxiety and fear; provide calming.
Rationale: The client will feel better when heard. trusting relationship can be established with the client.

3) Maintain a quiet environment.
Rationale: quiet surroundings make the client more relaxed and can reduce anxiety.

4) Provide diversion through television, radio, games for lowering anxiety.
Rational: to divert the mind from stress and anxiety.

5) Describe the procedures and actions and give an explanation of the strengthening of disease, and prognosis action.
Rationale: patient involvement in care planning can provide a sense of control and helps reduce anxiety.

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Nursing Interventions for Intestinal Obstruction : Imbalanced Nutrition

Nursing Care Plan for Intestinal Obstruction

Nursing Diagnosis : Imbalanced Nutrition Less Than Body Requirements

Intestinal obstruction is an urgency in abdominal surgery is often encountered, is 60-70% of all cases of acute abdomen were not acute appendicitis.

The most common cause is the adhesion / streng, while it is known that abdominal surgery and obstetric-gynecologic surgery performed more frequently which is mainly supported by advances in the field of diagnostic abdominal abnormalities.


Imbalanced Nutrition Less Than Body Requirements related to impaired absorption

characterized by: abdominal pain, quickly full after eating.

Goal: balanced nutrition.

Outcomes:

• Stable weight.
• Return to normal bowel sounds: 6-12x/menit.
• Bloating and abdominal distension decreased.

Nursing Interventions:

1) Assess the nutritional needs of the client.
Rationale: By knowing the nutritional needs of the client can be observed the extent of the client's nutritional deficiencies and subsequent action.

2) Observation of signs of nutritional deficiencies.
Rationale: To determine the extent to which lack of nutrients due to excessive vomiting.

3) Encourage activity restrictions during the acute phase.
Rationale: Reduces the need to prevent a decrease in metabolic calorie and energy savings.

4) Evaluate periodically the condition of intestinal motility.
Rationale: As the basic data for the provision of nutrition.

5) If the obstruction is severe, avoid oral intake.
Rationale: if the obstruction is severe, oral intake can aggravate abdominal distension.

6) Give parenteral nutrition.
Rationale: parenteral nutrition does not cause abdominal distension.

7) Give food in small portions but often.
Rational: small amounts of food can reduce gastric compliance and reduce compliance and reduce labor intestinal peristalsis and facilitate intestinal absorption of food right.

8) Provide oral care.
Rationale: The flavors are delicious, the smell of the mouth can decrease appetite and stimulates nausea and vomiting.

9) Collaboration with a nutritionist about the types of nutrients that will be used by the patient.
Rationale: Nutritionists should be involved in determining the composition and the type of food that will be provided in accordance with individual needs.

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