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

Herniated Nucleus Pulposus

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

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

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

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

Assessment Nursing Care Plan for HNP Herniated Nucleus Pulposus

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

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

3. Examination Support

Diagnosis Nursing Care Plan for HNP Herniated Nucleus Pulposus

1. Acute Pain

2. Impaired physical mobility

3. Anxiety

4. Knowledge deficient

Intervention Nursing Care Plan for HNP Herniated Nucleus Pulposus

1. Acute pain related to nerve compression, muscle spasm

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

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

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

3. Anxiety related to ineffective individual coping

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

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

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

4 Cataract Nursing Diagnosis and Interventions

4 Nursing Diagnosis and Interventions for Cataracts

Nursing Diagnosis for Cataract: Anxiety related to lack of knowledge.

Goal:
1. Lowering the emotional stress, fear and depression.
2. Acceptance and understanding instructions surgery.
Nursing Interventions for Cataract:

1. Assess the degree and duration of visual impairment. Encourage conversation to find out the patient's concerns, feelings, and the level of understanding.
Rational: Information can eliminate the fear of the unknown. Coping mechanisms can help patients with kegusara compromise, fear, depression, tension, despair, anger, and rejection.

2. Orient the patient to the new environment.
Rationale: The introduction to the environment helps reduce anxiety and increase security.

3. Explain the perioperative routines.
Rationale: Patients who have a lot of information easier to receive treatment and follow instructions.

4. Describes intervention much detail as possible.
Rationale: Patients who experience visual disturbances rely on other senses salts input information.

5. Push to perform daily living habits when able.
Rationale: Self-care and will increase the sense of healthy independence.

6. Encourage participation of family or the people who matter in patient care.
Rationale: Patients may not be able to perform all duties in connection with the handling of personal care.

7. Encourage participation in social activities and diversion whenever possible (visitors, radio, audio recording, TV, crafts, games).
Rationale: Social isolation and leisure time is too long can cause negative feelings.
Nursing Diagnosis for Cataract: Risk for injury related to blurred vision

Goal: Prevention of injury.

Nursing Intervenion for Cataract:

1. Help the patient when able to do until postoperative ambulation and achieve stable vision and adequate coping skills, using techniques of vision guidance.
Rational: Reduce the risk of falling or injury when the step stagger or have no coping skills for vision impairment.

2. Help the patient set the environment.
Rationale: Providing facilities of independence and lower the risk of injury.

3. Orient the patient in the room.
Rationale: Improving safety and mobility in the environment.

4. Discuss the need for the use of metal shields or goggles when instructed
Rational: shield l; ogam or goggles protect the eyes against injury.

5. Do not put pressure on the affected eye trauma.
Rational: The pressure in the eye may cause further serious damage.

6. Use proper procedures when providing eye drugs.
Rational: Injury can occur if the container touch the eye medication.
Nursing Diagnosis for Cataract: Acute pain related to trauma to the incision and increased IOP

Goal: Reduction of pain and the IOP.

Nursing Interventions for Cataract:

1. Give medications to control pain and the IOP as prescribed.
Rational: Use the recipe will reduce pain and the IOP and increase comfort.

2. Give cold compress on demand for blunt trauma.
Rational: reduce the edema will reduce the pain.

3. Reduce the level of pencayahaan
Rationale: The level of lighting is more nyakan lower after surgery.

4. Encourage use of sunglasses in strong light.
Rasioanal: Strong light causes discomfort after use of eye drops dilator.
Nursing Diagnosis for Cataract: Risk for infection related to trauma to the incision

Goal: Complications can be avoided or promptly reported to the doctor.

Nursing Interventions for Cataract:

1. Maintain strict aseptic technique, do wash your hands frequently.
Rationale: It would minimize infection.

2. Supervise and report immediately any signs and symptoms of complications, such as: bleeding, increased IOP or infection.
Rational: The discovery of early complications can reduce the risk of permanent vision loss.

3. Explain the recommended position.
Rational: Elevation of the head and avoid lying on the side of the operation may reduce the edema.

4. Instruct the patient to know bedrest activity restrictions, with flexibility to the bathroom, according to a gradual increase in activity tolerance.
Rational: Limitation of activity prescribed to speed healing and avoid further damage to the injured eye.

5. Describe the actions that should be avoided, as prescribed by coughing, sneezing, vomiting (ask for medication for it).
Rational: It can lead to complications such as vitreous prolapse or dehisensi injury due to increased tension on the suture wounds that are very subtle.

6. Give medications as prescribed, according to prescribed techniques.
Rational: Drugs are administered in a way that is inconsistent with prescriptions can interfere with healing or cause complications.

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

Nursing Diagnosis for Congestive Heart Failure (CHF)

Activity Intolerance

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

Characterized by:

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

Goals / evaluation criteria:

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

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

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

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

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

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

Nursing Care Plan for Hypertension : Assessment, Diagnosis and Interventions

Hypertension

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

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

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

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

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

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

Nursing Care Plan for Hypertension

Nursing Assessment Nursing Care Plan for Hypertension

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

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

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

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

d. Elimination include: history of kidney disease.

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

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

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

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

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

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

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

a. Decreased cardiac output

b. Activity intolerance

c. Acute pain

d. Imbalanced Nutrition: More Than Body Requirements

e. Ineffective coping

Nursing Diagnosis and Interventions for Hypertension

Nursing Diagnosis of Acute Pain related to Constipation

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

Goal: show pain has been reduced

Expected Outcomes:

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

Nursing Interventions Acute Pain related to Constipation

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

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

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

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

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

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

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

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

Constipation Nursing Care Plan: Diagnosis and Interventions

Nursing Diagnosis: Constipation related to irregular bowel habit

Purpose: patients can defecate regularly (every day)

Expected outcomes:

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

Nursing Interventions for Constipation

Independent

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

Collaboration

Provision of laxatives or enemas as indicated

Rational:

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

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

Purpose: demonstrate good nutritional status

Expected Outcomes:

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

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

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

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

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

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

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

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

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

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

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

Nursing Diagnosis and Interventions for Heart Failure

Nursing Diagnosis for Heart Failure 1.

Decreased cardiac output related to changes in myocardial contractility.

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

Nursing Interventions :

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

Nursing Diagnosis for Heart Failure 2.

Activity intolerance related to imbalance between supply oxygenation needs.

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

Nursing Interventions :

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

Nursing Diagnosis for Heart Failure 3.

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

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

Nursing Interventions :

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

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