Acute Pain / Chronic Pain - NCP for Rheumatoid Arthritis

Nursing Care Plan for Rheumatoid Arthritis

The changes will occur in the human body in line with the increasing age. Body changes occur early in life until old age in all organs and tissues of the body. Such circumstances also appears on all of the musculoskeletal system and other tissues related to the possibility of some classes of rheumatism. Such circumstances it appears also in all other tissues of the musculoskeletal system and that has to do with the possibility of some classes of Rheumatoid Arthritis. Rheumatoid Arthritis can lead to changes in the muscle, until the function can be decreased when the muscles in the suffering does not trained to activate muscle function. With increasing age old muscle function can be properly trained. But old age is not always experienced or suffered from rheumatism. How the onset of rheumatic this incident, until now has not been fully understood.

According to the consensus of the experts in the field of rheumatology, rheumatism can be expressed as a complaint and / or markings. Of the agreement, otherwise there are three main complaints of the musculoskeletal system are: pain, stiffness and weakness, as well as the three main signs are: swelling of the joints, Muscle weakness, and movement disorders. (Soenarto, 1982).

Rheumatoid arthritis is a long case very often tested. Usually there are many physical signs. Diagnosis of the disease is easily enforced. Management is often a major problem. The incidence of rheumatoid arthritis peaks occur in the fourth decade of age, and the disease is found in women 3 times more often than men. Rheumatoid arthritis is believed to be an immune response to an unknown antigen. Stimulus can be viral or bacterial. There may also predispose to the disease.


Definition

Rheumatoid arthritis is a chronic multisystem disease of unknown cause, is a characteristic feature of rheumatoid arthritis; persistent synovial inflammation, usually of the peripheral joints in a symmetric distribution (Harrison, 2000: 1840).

Rheumatoid arthritis is a chronic disorder that attacks a variety of organ systems, this disease is one of a group of diffuse connective tissue diseases mediated by immune and unknown cause (Sylvia A.Price, 2005: 1385).


Etiology

According to Harrison (2000 : 1841), the cause of rheumatoid arthritis is unknown, it is likely a manifestation of rheumatoid arthritis in response to an infectious agent. One of the possible presence of persistent infection in the joint structure or retention of microbial products in the synovial tissue that trigger chronic inflammatory response. Another potential causative mechanism in rheumatoid arthritis is a disruption of the normal self tolerance which cause reactivity against self antigens in the joints.

But the biggest factor precipitating factors of rheumatoid arthritis is an infection such as bacteria, mycoplasma and viruses (Lemone & Burke, 2001). The main cause of this disorder is unknown. There are several theories put forward as to the cause of rheumatoid arthritis, namely:

1. Haemolytic streptococcal infection and non-haemolytic streptococci.
2. Endocrine
3. Autoimmune
4. Metabolic
5. Genetic factors as well as other trigger factors.

At this time, suspected rheumatoid arthritis is caused by autoimmune and infectious factors. This autoimmune reaction against collagen type II; factor for infection may be caused by a virus and mycoplasma organism or group of diphtheroids which produce collagen type II antigens of joint cartilage patients.


Clinical Manifestations

Criteria of the American Rheumatism Association (ARA) 1987 revised are:

1. Stiff in the morning. Patients feel stiff in the joints and surrounding from waking up at least one hour before maximal improvement.
2. Arthritis in the three regions. Swelling of soft tissue or bone enlargement joints instead, occurs in at least three joints simultaneously. There are 14 joints that meet the criteria: proximal interphalangeal, metacarpophalang, wrist, elbow, ankle, and metatarsophalangeal left and right.
3. Artrtis on hand joints. At least there is swelling of the joints of the hands as shown above.
4. Symmetrical arthritis. That is the involvement of the same joint (not absolutely symmetrical) on both sides simultaneously.
5. Rheumatoid nodule is a local swelling or tissue lump, usually rather firm to the touch, like an unripe fruit, the which Occurs almost exclusively in association with rheumatoid arthritis.
6. Serum rheumatoid factor positive. There abnormal titers of serum rheumatoid factor were examined in a way that gives a positive result is less than 5% of the control group.
7. There is a typical radiological changes on chest X-ray examination postero-anterior hand or wrist, which should indicate the presence of erosions or decalcification of bones located at joints or areas adjacent to joints.

The diagnosis of rheumatoid arthritis is made if at least four of the seven criteria are met above. Criteria 1 till 4 there must be at least 6 weeks.



Nursing Diagnosis for Rheumatoid Arthritis : Pain Acute / Chronic Pain

Acute Pain / Chronic related to the agent of injury, tissue distension by the accumulation of fluid / inflammation, joint destruction.

Outcomes:
Shows the pain is relieved / controlled,
Looks relaxed, sleep / rest and participate in activities according to ability.
Following the prescribed pharmacological programs,
Combining the skills of relaxation and entertainment activities in a pain control program.

Intervention and Rational:
1. Assess pain, note the location and intensity (scale of 0-10). Note the factors that accelerate and signs of non-verbal pain.
R / : Assist in determining the need for pain management and program effectiveness.

2. Provide mat / hard mattress, small pillows. Elevate the patient's bed linens as needed.
R / : Mattress soft / soft, big pillows will prevent the maintenance of proper body alignment, putting stress on diseased joints. Elevation of the bed linens pressure on inflamed joints / pain.

3. Place / monitor the use of pillows, sandbags, rolls trokhanter, splint, brace.
R / :Resting sore joints and maintain a neutral position. The use of the brace can reduce pain and can reduce damage to the joints.

4. Pushes to frequently change positions, help to move in bed, prop joints above and below sick, avoid jerky movements.
R /: Prevent the occurrence of general fatigue and joint stiffness. Stabilize the joint, reducing movement / joint pain

5. Instruct the patient to a warm bath or shower to wake-up time and / or at bedtime. Provide a warm washcloth to compress the affected joints several times a day. Monitor the temperature of the water compresses, bath water, and so on.
R /: Heat improves muscle relaxation, and mobility, decrease pain and stiffness in the morning release. Sensitivity to heat can be removed and dermal wounds can be healed.

6. Provide gentle massage.
R /: Increase relaxation / reduce pain.

7. Encourage use of stress management techniques, such as progressive relaxation, therapeutic touch, biofeedback, visualization, imagination guidance, self hypnosis, and breath control.
R /: Increase relaxation, gives a sense of control and may improve coping skills

8. Involve in entertainment activities appropriate to the individual situation.
R /: Refocus attention, stimulate, and improve self-confidence and feeling healthy.

9. Give medication before activity / exercise planned as directed.
R /: Increase realaksasi, reduce muscle tension / spasm, making it easy to participate in therapy.

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Activity Intolerance and Impaired Verbal Communication NCP for Myasthenia Gravis

Myasthenia gravis is characterized by weakness and rapid fatigue of any muscle out of control. The cause of myasthenia gravis is a breakdown in the normal communication between nerves and muscles. Myasthenia gravis can affect people of any age, but it often occurs in women younger than 40 and in men more than 60 years.

Myasthenia gravis can affect any muscle, but the most commonly affected are the muscles that control eye movements, eyelids, chewing, swallowing, coughing and facial expressions. Shoulders, hips, neck, muscles that control body movement and muscle that helps breathing can also attacked.

Myasthenia Gravis Patients are usually not the same from one person to another person. Based on the data, the disease is still relatively rare because the lack of knowledge about the symptoms of the disease.

The symptoms that arise are the some of the weaker muscles. The muscles most frequently attacked are the muscles that control eye movements, eyelids, speech, swallowing, chewing, and more severe respiratory muscles are attacked.

In 90% of patients with Myasthenia Gravis initial symptoms appear is the ocular muscles that cause the decrease eyelids and double vision. Clearly visible physically. Obviously the symptoms will appear and spread further attack other muscles. Until a more severe attack the respiratory muscles are usually visible from weakening cough. In fact there is shortness of breath and can be fatal.


Nursing Diagnosis for Myastenia Gravis

Activity intolerance related to muscle weakness

Characterized by:
Subjective Data:

• Patients say tired after doing the activity.
• Patients report muscle weakness.

Objective Data:

• Patient seems tired and listless.
• Patient was not able to take action to meet their daily needs.
• Increased pulse.
• Increased blood pressure.
• Breathing increases.
• Decreased muscle strength.

Outcomes:

• Full muscle strength.
• Atrophy does not occur.
• Good muscle tone.
• Patients can perform the activity gradually.
• Muscle weakness does not occur.

Intervention:
1. Assess the strength of muscles, ptosis, diplopia, eye movement, ability to chew, swallow, cough reflex, talk.
R /: The rate of muscle weakness may be different in other parts of the body.

2. Assess muscle strength before and after drug administration.
R /: Knowing the effects of drug administration.

3. Perform scheduled breaks, keep quiet surroundings.
R /: Period after the break, increased muscle strength.

4. Encourage participation in treatment.
R /: Train activity gradually.


Nursing Diagnosis for Myastenia Gravis

Impaired verbal communication related to muscle weakness.

Characterized by:
Subjective Data:

• Patients say difficulty speaking

Data Objective :

• Patients appear to difficulties in verbal expression.
• Changes in behavior are not willing to communicate.
• The use of sign language / body.

Outcomes:
Patients expressing themselves verbally or non-verbally.

Intervention:
1. Assess the patient's ability to speak with the examination of cranial nerves V, VII, IX, X, XII.
R /: knowing the patient's ability to speak.

2. Ask a closed question, yes or no or body movements.
R /: Facilitate patient easily answered.

3. Talk with slow motion.
R /: Can see the speaker's lip movements.

4. Use images, paper or other means.
R /: Using media allows patients to express desire.

5. Inform staff or family, about the limitations of the patient in communication.
R /: Communication patterns that one would add to the frustration of patients.

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7 Abnormalities In The Nervous System

Neurology is a branch of medical science that deal with disorders of the nervous system. Doctors that specialize in the field of neurology are called neurologists and has the ability to diagnose, treat, and management of patients and neurological disorders. Most neurologists are trained to deal with adult patients.

For children performed by a pediatric neurologist, which is a branch of pediatrics. The neurologist deal with disorders of the nervous system, including the central nervous system (brain, brainstem, and cerebellum), the peripheral nervous system (eg brain nerve), and the autonomic nervous system. Neurology can also diagnose and examine a few cases on the muscular system and bones (musculoskeletal). Some examples of abnormalities that occur in the nervous system, among others:

1. Stroke (Cerebrovascular accident (CVA) or cerebral apoplexy) is damage to the brain due to blockage or rupture of blood vessels of the brain.
2. Poliomyelitis is a disease caused by a viral infection that attacks the motor neurons of the nervous system (brain and spinal cord).
3. Epilepsy is a disease due to release electric eruptions (impulse) in the neurons of the brain.
4. Parkinson's is a disease caused by reduced dopamine neurotranslator, on the basis of ganglion with symptoms; hand tremor at rest (but shaking was lost during sleep), difficulty moving, muscle rigidity, stiff facial muscles making it appear as if masked, hard eyes blink and move be small and stiff legs.
5. Transection is damage or a certain segment of the entire spinal cord. For example, due to a fall, which is accompanied by a predictable destruction of the spine.
6. Neurasthenia (nervous weakness), the disease is there because of a congenital, too heavy sufferer, spiritually too weak, or because of illness poisoning.
7. Neuritis is inflammation of the nerves which happens due to physical influences such as broken bones, punch pressures, and may also be due to toxins or deficiency of vitamin B1, B6, B12.

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Acute Pain and Bleeding relatde to Ectopic Pregnancy

An ectopic pregnancy is a pregnancy that occurs and is beyond the normal endometrial, endometrial echogenic thickened, as a result of decidual reaction. Uterine cavity is often filled with fluid exudates produced by the decidual cells on examination is seen as anechoic ring structure, called pseudogestational sac.


Signs and symptoms

1. Signs and symptoms of ectopic pregnancy

• Early pregnancy symptoms (spots or irregular bleeding, nausea, breast enlargement, discoloration of the vagina and cervix, softening the cervix, uterine enlargement)
• Pain in the abdomen and pelvis.

2. Signs and symptoms of ruptured ectopic pregnancy

• Collapse and fatigue.
• The pulse is rapid and weak.
• Hypotension.
• Hypovolemia.
• Acute abdominal pain and pelvic.
• Abdominal distension.
• Rebound tenderness.
• Pale.

Signs and symptoms depend on the length of an ectopic pregnancy, ruptured ectopic pregnancy, abortion, or tubal rupture, gestational age at the time, the degree of bleeding that occurs, and the general state of the patient before pregnancy.

1. Pain.

Pain is the main complaint in ruptured ectopic pregnancy. In tubal rupture, lower abdominal pain occurs suddenly and intensity, accompanied by bleeding that causes people to faint and shock occurs. Usually the tubal abortion, pain is not how great and not continuously. The pain initially located on one side; However, after the entry of blood into the abdominal cavity, pain radiating to the middle or to the entire lower abdomen. Blood in the abdominal cavity can stimulate the diaphragm, causing shoulder pain, and when forming retrouterine hematocele, causing painful defecation.

2. Vaginal bleeding

Vaginal bleeding is an important sign of both the ruptured ectopic pregnancy, suggesting that it is derived from the fetal death and uterine cavity due to the release of the decidua. Bleeding from the uterus and are usually not a lot of dark brown. Bleeding usually occurs around 51-93% on a ruptured ectopic pregnancy. Bleeding means impaired formation of hCG. If there is a solutio placenta decidua can be removed entirely.

3. Amenorrhoea.

Amenorrhoea is the third important sign of ectopic pregnancy, duration of amenorrhea depends on the gestation of the fetus, so it can vary. Most patients do not experience amenorrhea due to fetal death occurred before the next menstruation. Amenorrhea incidence of ectopic pregnancy ranges from 23-97%.

4. On vaginal examination, was found protruding cavity and pain on palpation. Retrouterine hematocele palpable as tumors in douglas cavity, which causes bleeding, and a decrease in blood pressure, increased pulse, and the risk of shock.


Clinical manifestations of ruptured ectopic pregnancy depends on its location. Signs and symptoms vary greatly depending on whether or not the pregnancy ruptured. The symptoms and laboratory test results include:

1. Gastrointestinal complaints.

The most frequent complaints expressed by patients ruptured ectopic pregnancy is pelvic pain. Dorfman stressed the importance of gastrointestinal complaints and vertigo or dizziness. All of these complaints have diversity in terms of incidence due to the speed and extent of bleeding in addition to late diagnosis.

2. Abdominal and pelvic tenderness.

Arising tenderness on palpation of the abdomen and examination, especially by moving the cervix, found in more than three-quarters of cases of ectopic pregnancy or are already experiencing rupture, but it is sometimes not seen before rupture occurrence.

3. Amenorrhea.

History of amenorrhea is not found in a quarter of cases or more. One reason is because patients assume a common vaginal bleeding ectopic pregnancy as a normal menstrual period, thus giving a false date of last menstrual period.

4. Vaginal spotting or bleeding.

During the endocrine functions of the placenta still survive, uterine bleeding usually are not found, but when the endocrine support of the endometrium is no longer sufficient, uterine mucosa will experience bleeding. Bleeding is usually a little, colored dark brown and can be intermittent or persistent.

5. Uterine changes.

Uterus in ectopic pregnancy can be pushed to one side by the ectopic period. In the broad ligament pregnancy or blood filled the broad ligament, the uterus can be shifted great. Uterine cast will be excreted by a minority of patients, perhaps 5% or 10% of patients. Excretion cast fibroids can be accompanied by cramping symptoms similar to networking events abortion spontaneous expulsion of the uterine cavity.

6. Blood pressure and pulse rate.

The initial reaction to the hemorrhage was no change in pulse rate and blood pressure, or sometimes the same reaction as seen in action to be a blood donor phlebotomy is mild increase in blood pressure or vasovagal response accompanied by bradycardia and hypotension.

7. Hypovolemia.
Noticeable drop in blood pressure and pulse rate rise in a sitting position is most often a sign that showed a decrease in blood volume that is quite a lot. All of these changes may have occurred after the onset of serious hypovolemia.

8. Body temperature.
After the acute bleeding, the body temperature may remain normal or even decreased. Higher temperatures rarely found in a state without an infection. Because the heat is a picture that is important to distinguish between who experienced rupture of tubal pregnancy with acute salpingitis, which in this state of body temperatures generally above 38oC.

9. Pelvic mass.
Pelvic mass may be palpable at ± 20 % of patients. The period has the size , consistency and position vary. Usually this mass measuring 5-15 cm , often palpable soft and elastic. However, with the extensive infiltration of the tube wall by the blood of the past can be felt hard. Almost always found in the past pelvic posterior or lateral side of the uterus. Complaints of pain and tenderness often precede palpable in the pelvis future action palpation.

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Nursing Care Plan and 5 Diagnosis for Bronchitis

Acute bronchitis is an inflammation of the bronchi are usually the trachea and larynx, so often named by laringotracheobronchitis. This inflammation can arise as airway abnormalities alone or as part of a systemic disease, for example in morbili, pertussis, diphtheria, and typhoid abdominalis.

The term chronic bronchitis showed abnormalities in the bronchus that are chronic (long lasting) and is caused by various factors, including the factors that originate outside of the bronchus and bronchus itself. Chronic bronchitis is a condition associated with excessive tracheobronchial mucus production, causing a cough that occurs for at least three months in a year for more than two consecutive years.

There are three main factors that affect the incidence of bronchitis is smoking, infection and pollution.

1. Smoking
According to the Report of the WHO Expert Committee on Smoking Control, smoking is a major cause of bronchitis. There is a close relationship between smoking and decreased forced expiratory volume in 1 second. In pathological cigarettes associated with bronchial mucus gland hyperplasia and squamous metaplasia of respiratory epithelium can also cause acute bronchoconstriction.

2. Infection
Most often mistaken for bronchitis exacerbations preceded by a viral infection which then causes secondary bacterial infection. Bacteria isolated most is Hemophilus influenza and Streptococcus pneumoniae.

3. Pollution
Pollution is not so great influence as a causative factor, but when added to a higher risk of smoking. The chemicals can also cause bronchitis are reducing agents such as O2, oxidizing substances such as N2O, hydrocarbons, aldehydes, ozone.


Acute bronchitis can be a complication of pathologic abnormalities in several organs, namely:

• Chronic heart disease, which is caused by pathologic abnormalities in the valves and myocardium. Chronic congestion on the wall of the bronchus weaken resistance to bacterial infection easily occur.
• Paranasalis sinus infections and oral cavity, the area is a source of bacterial infections that can invade the wall of the bronchus.
• Dilatation of the bronchi (bronchiectasis), cause the composition and function of bacterial infection of the bronchial walls so easily happen.
• Smoking can cause paralysis of the bronchus mucous membranes vibrating bristles that impaired mucus drainage. The set of mucus is a good medium for bacterial growth.

5 Nursing Diagnosis for Bronchitis

1. Ineffective airway clearance r / t increased production of secretions.

2. Impaired gas exchange r / t obstruction of the airway by secretions, spasm of the bronchi.

3. Ineffective breathing pattern r / t bronchoconstriction, mucus.

4. Imbalanced Nutrition Less than Body Requirements r / t dyspnoea, anorexia, nausea, vomiting.

5. Risk for infection r / t secretions persistence, chronic disease processes.

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Acute Pain - Nursing Diagnosis and Interventions for Urolithiasis

Kidney stones in the urinary tract (urinary calculus) is hard as a rock mass formed in the urinary tract and can cause pain, bleeding, infection or blockage of urine flow.

These stones can form in the kidneys (kidney stones) and in the bladder (bladder stones).
The process of stone formation is called urolithiasis (renal lithiasis, nephrolithiasis). The concentration of stone-forming substances high in blood and urine as well as eating habits or certain medications, can also stimulate the formation of stones. Anything that impedes the flow of urine and cause stasis (no movement) in the urine anywhere in the urinary tract, increasing the likelihood of stone formation.

Stone, especially small ones, may not cause symptoms. Stone in the bladder can cause pain in the lower abdomen. Stones that obstruct the ureter, renal pelvis and renal tubules can cause back pain or renal colic (severe colicky pain). Renal colic is characterized by severe pain intermittent, usually in the area between the ribs and hip bones, which spread to the abdomen,  pubic area and inner thighs. Other symptoms are nausea and vomiting, abdominal distention, fever, chills and blood in the urine. Patients may be frequent urination, especially when the stone passes through the ureter. Stones can cause urinary tract infections. If stones block the flow of urine, the bacteria will be trapped in the urine collected over the blockage, so that there was an infection. If the blockage lasts long, the water will flow back into the urinary tract in the kidney, leading to suppression of which would inflate the kidneys (hydronephrosis) and eventually kidney damage can occur.

Common symptoms of kidney stone disease are:

• Urinate more often occurs
• Pain at the waist
• Sometimes accompanied by fever and seizures
• Cloudy yellow urine
• A history of kidney stones who previously suffered by one member of the family

Nursing Diagnosis for Urolithiasis : Acute Pain related to increase in the frequency of ureteral contractions, tissue trauma, edema and cellular ischemia.

Nursing Interventions:

1. Record the location, duration / intensity of pain (scale 1-10) and its spread. Pay attention to non-verbal signs such as: increase in BP and pulse rate, restlessness, grimacing, moaning, floundering.

2. Explain the causes of pain and the importance of reporting to the nursing staff of any changes that occur pain characteristics.

3. Perform actions that promote comfort (such as light massage / warm compress on the back, quiet environment)

4. Help the patient to deep breathing, guided imagery and therapeutic activity.

5. Help / encourage increased activity (ambulation active) as indicated with at least 3-4 liters of fluid intake per day within cardiac tolerance.

6. Note the increase / persistence of abdominal pain.

7. Collaboration of appropriate drug therapy program.

8. Maintain urinary catheter patency when needed.


Rational:

1. Help evaluate the progress of obstruction and stone movement. Pelvic pain often spreads to the back, groin, genitalia with respect to proximity plexus nerves and blood vessels that supply the other areas. Sudden pain and can lead to severe anxiety, fear / anxiety.

2. Reported early pain, analgesic provision provides an opportunity at the right time and help improve the client's coping ability in reducing anxiety.

3. Promote relaxation and reduce muscle tension.

4. Divert attention and help to relax the muscles.

5. Physical activity and adequate hydration increases the passage of the stone, prevent urinary stasis and prevent further stone formation.

6. Complete obstruction of the ureter may lead to perforation and ekstravasasiurine into perrenal area, this is an acute surgical emergency.

7. Prevent stasis / urinary retention, lowering the risk of increased pressure and kidney infections.

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Acute Tonsillitis - 6 Nursing Diagnosis Care Plan

Definition;

Tonsillitis is a common presence of inflammation and swelling of the tonsillar tissue with a collection of leucocytes, dead epithelial cells and pathogenic bacteria in the crypts (Adam Boeis, 1994: 330).

Tonsillectomy is an invasive procedure that is performed to take out tonsils with or without adenoid (Adam Boeis, 1994: 337).


Etiology 

1. Haemolytic streptococcus group A.
2. Pneumococcus.
3. Staphylococci.
4. Haemophilus influenzae.

Symptoms 

1. Sore throat and dysphagia.
2. Patients do not want to eat or drink.
3. Malaise.
4. Fever.
5. Breath odor.
6. Otitis media is one of the originators factor.

Management of Acute Tonsillitis

1. Bed rest.
2. Provision of adequate fluids and light diet.
3. Giving medications (analgesics and antibiotics).
4. If there is no progress then the alternative actions that can be done is surgery.

Nursing Assessment for Acute Tonsillitis

1. Medical history factors associated with the occurrence of tonsillitis as well as supporting the bio-psycho-socio-spiritual.

2. Circulatory
Palpitations, headache at the time of a change in position, drop in blood pressure, bradycardia, body felt cold, pale extremities appear.

3. Elimination
Changes in the pattern of elimination (incontinence uri / Alvi), abdominal distension, bowel sounds disappearance.

4. Activity / rest
There is a decrease in activity due to body weakness, loss of sensation or parese / plegia, tiredness, difficulty in recuperating from muscle spasms and pain or spasm. The reduced level of consciousness, decreased muscle strength, general body weakness.

5. Nutrition and fluids
Anorexia, nausea, vomiting due to increased ICP (intracranial pressure), impaired swallowing, and loss of sensation on the tongue.

6. Nerves system
Dizziness / syncope, headache, decreased visual field wider / blurred vision, decreased touch sensation, especially in the face and extremities. Mental status coma, kelmahan in the extremities, facial muscles paralise, aphasia, dilated pupils, decreased hearing.

7. Comfort
Tense facial expressions, headache, restlessness.

8. Breathing
Shortened breath, inability to breathe, apnea, apnea onset period in breathing patterns.

9. Security
Fluctuations of temperature in the room.

10. Psychology
Denial, disbelief, anguish, fear, anxiety.



Nursing Diagnosis and Interventions for Acute Tonsillitis


1. Ineffective breathing pattern related to tissue damage or trauma to the respiratory center.

Goal: The patient demonstrated the ability to perform adequately the respiratory blood gas results show stable and good as well as the loss of signs of respiratory distress.

Interventions

1. Clear the airway patent (keep the head position in a state parallel to the spine / as indicated).
2. Perform suction if necessary.
3. Assess the function of the respiratory system.
4. Assess the patient's ability to perform cough / discharging effort.
5. Observation of vital signs before and after the action.
6. Observation for signs of respiratory ditress (skin becomes pale / cyanosis).
7. Collaboration with therapists in the provision of physiotherapy.

2. Impaired physical mobility related to neuromuscular weakness in the extremities.

Goal: Patients showed an increased ability to perform physical activity.

Interventions:

1. Assess the patient's ability to perform the activity.
2. Teach the patient about the range of motion that can still be done.
3. Perform active and passive exercises at akstrimitas to prevent stiffness and muscle atrophy.
4. Instruct the patient to take a straight position.
5. Assist patients in performing ROM gradually according to ability.
6. Collaboration in the provision antispamodic or relaxant if necessary.
7. Observation of the patient's ability to perform the activity.

3. Ineffective Cerebral Tissue Perfusion related to the brain, bleeding in the brain.

Goal: The patient showed an increase in awareness, cognitive and sensory function.

Interventions:

1. Assess neurologic status and note the changes.
2. Give the patient supine position.
3. Collaboration in the provision of oxygenation.
4. Observation level of consciousness, vital signs.

4. Acute pain related to physical trauma.

Goal: The patient expresses pain is reduced and shows a relaxed and calm state.

Interventions:

1. Assess the level or degree of pain felt by the patient using a scale.
2. Help the patient in finding factor in precipitation of pain felt.
3. Create a quiet environment.
4. Teach and demontrasikan to patients about several ways to do relaxation techniques.
5. Collaboration in the provision of appropriate indications.

5. Impaired verbal communication related to the effects of damage to the area to talk to the cerebral hemispheres.

Goal: The patient was able to communicate to meet their basic needs and showed improvement in their communication capabilities.

Interventions:

1. Do a personal communication with the patient (often but short and easy to understand).
2. Create an atmosphere of acceptance of the changes experienced by the patient.
3. Instruct patients to improve communication techniques.
4. Use non-verbal communication techniques.
5. Collaboration in the implementation of speech therapy.
6. Observation of the patient's ability to communicate both verbally and non-verbally.

6. Self-concept Disturbance related to a change of perception.

Goal: The patient showed improvement in the ability to accept the circumstances.

Interventions:

1. Assess the patient's degree of self-concept change.
2. Mentor and listen to patient complaints.
3. Give support to actions that are positive.
4. Assess the patient's ability to rest (sleep).
5. Observation of the patient's ability to receive state.

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