Nursing Diagnosis and Nursing Intervention


Hyperthermia and Acute Pain related to Dengue Fever Hemorrhagic (DHF)

Hyperthermia and Acute Pain related to Dengue Fever Hemorrhagic (DHF)
Hyperthermia r/t Dengue Fever Hemorrhagic (DHF)
Nursing Diagnosis : Hyperthermia related to disease process (viremia)

Goal :
Patient 's body temperature can be reduced.

Outcome :
  • Comfortable body condition.
  • Temperature 36,80C-37,50C.
  • Blood pressure : 120/80 mmHg.
  • Respiration : 16-24 x / mnt.
  • Pulse : 60-100 x / mnt.

Intervention :
  • Assess the onset of fever.
  • Observation of vital signs (temperature, pulse, blood pressure, respiration) every 3 hours.
  • Instruct the patient to drink (2.5 liters / 24 hours).
  • Give warm compresses.
  • Suggest to not wear thick blankets and clothing.
  • Give intravenous fluid therapy and medications as ordered.

Rationale :
  • To identify patterns of fever.
  • Vital Signs is a reference to determine the patient's general condition.
  • The increase in body temperature results in increased evaporation body so it needs to be balanced with a high fluid intake.
  • With vasodilation can increase evaporation which accelerates the decline in body temperature.
  • Clothing thin body helps reduce evaporation.
  • Fluid administration is very important for patients with a high temperature.


Nursing Diagnosis : Acute Pain related to pathological disease process.

Goal :
Patient's pain can be reduced and disappeared.

Outcomes :
  • The patient said that the pain was reduced / lost.
  • The pain was on a scale of 0-3.
  • Blood pressure : 120/80 mmHg.
  • Temperature : 36,80C-37,50C.
  • Respiration : 16-24 x / mnt.
  • Pulse : 60-100 x / mnt.

Intervention :
  • Observation of the patient's level of pain (scale, frequency, duration).
  • Provide a quiet and comfortable environment and comfort measures.
  • Give proper entertainment activities.
  • Involve families in nursing care.
  • Teach the patient relaxation techniques.
  • Collaboration with physicians to analgesic drug delivery.

Rationale :
  • Indicates the need for intervention and also the signs of the development / resolution of complications.
  • A comfortable environment will help the process of relaxation.
  • Refocused attention ; improve the ability to cope with pain.
  • Family will help the healing process by training the patient relaxation.
  • Relaxation pain will move to other things.
  • Provide pain relief.

Signs and Symptoms of Psychiatric Disorders : Motor Behavior

Aspects of life including impulse, motivation, hope, encouragement, instinct and craving, as expressed by one's behavior or motor activity.

1. Echopraxia : Echopraxia is the involuntary repetition or imitation of another person's actions.

2. Catatonia : motor abnormalities in non-organic disorders (as opposed to a disturbance of consciousness and motor activity of secondary organic pathology).
  • Catalepsy : a general term for a position that does not move continuously maintained.
  • Catatonic furor : agitated motor activity, not intended and are not influenced by external stimulation.
  • Catatonic stupor : a real decrease in motor activity, often to the point of immobility and seemed unaware of surroundings.
  • Catatonic Rigidity : acceptance of a rigid posture conscious, against attempts to be moved.
  • Catatonic posturing : acceptance inappropriate posture or rigid conscious, usually maintained for a long time.
  • Flexibility cerea (waxy flexibility) : Waxy flexibility is a psychomotor symptom of catatonic schizophrenia which leads to a decreased response to stimuli and a tendency to remain in an immobile posture.

3. Negativism : detention without motivation against any attempt to move or to all instructions.

4. Cataplexy : cataplexy is a sudden and transient episodes of muscle weakness accompanied by full conscious awareness, typically triggered by emotions such as laughing, crying, terror, etc.

5. Stereotypies : A stereotypy is a repetitive or ritualistic movement, posture, or utterance. Stereotypies may be simple movements such as body rocking, or complex, such as self - caressing, crossing and uncrossing of legs, and marching in place.

6. Mannerism : the movement is not realized, and are habitual.

7. Automatism : action or automatic actions that usually represents a symbolic activity that is not realized.

8. Command automatism : automatism follow the suggestion (also called automatic compliance).

9. Mutism : silent without structural abnormalities .

10. Overactivity :
  • Psychomotor agitation : overactivity of motor and cognitive overload, usually not productive and as a result of a response to the tension in the (inner tension).
  • Hyperactivity / hyperkinesis : anxiety and destructive activity, often accompanied by the basic pathology in the brain.
  • Tick : motor movements are spasmodic and unconscious.
  • Sleep walking ( somnambulisme ) : motor activity while asleep.
  • Akathisia : subjective feelings of tension to the motor as a side effect of antipsychotic medications, or other medications that can cause anxiety ; sitting and standing are alternated repeated and repeated ; can be misinterpreted as psychotic agitation.
  • Compulsion : uncontrollable impulse to perform repetitive actions.
Dipsomania : compulsion to drink alcohol.
Kleptomania : compulsion to steal.
Nymphomaniac.
Satiriasis.
Trichotillomania : compulsion to pull out hair.
Ritual : automatic compulsive activity in nature, lowering the original anxiety.
  • Ataxia : failure of muscle coordination, muscle movement irregularities.
  • Polyphagia : pathological overeating.

11. Hypo - activity / hypo - kinesis : motor activity and cognitive decline , such as psychomotor retardation ; slowing the mind , speech and movement that can be seen .

12. Mimicry : artificial and simple motor activity in children .

13. Aggression : stronger and directed action goals that may be verbal or physical ; motor part of the affective violence , anger or hostility .

14. Acting ( acting out ) : the direct expression of a hope or an unconscious impulse in the form of movement ; unconscious fantasy turned impulsively in behavior .

15. Abulia : decrease impulse to act and think , accompanied by indifference about the consequences of actions ; accompanied by neurological deficits .

16. Vagaboundage : like wandering the streets aimlessly .

Mental State Examination : Affect and Mood


Affect and Mood

A complex feeling state with psychic, somatic and behavioral components related to
affective and mood.

Affect

Afek is a visible expression of emotion ; may not be consistent with the emotions that said the patient.
  1. Appropriate Affect : emotional rhythm harmonious conditions ( corresponding, synchronized) with the idea, thought or conversation that accompanies ; further described as a wide or full affect, in which a complete emotional range expressed accordingly.
  2. Inappropriate Affect : disharmony between the emotional rhythm with ideas, thoughts or conversation.
  3. Blunted Affect : the affective disorders manifested by severe decline in the intensity of feeling expressed rhythm out.
  4. Restricted or constricted Affect : reduction in the intensity of the rhythm feeling less severe than the effects of blunt but clearly decreased.
  5. Fiat Affect : no or almost no signs of affective expression ; monotonous voice, a face that does not move.
  6. Labile Affect : feeling rhythm changes quickly and abruptly, which is not related to external stimulation.

Mood

Mood is an emotion that permeated maintained, subjectively experienced and reported by patients and seen by others. Examples are depression, elasi, anger.
  1. Dysphoric mood : an unpleasant mood.
  2. Euthymic Mood : mood within the normal range, suggesting the presence of depressed mood or soar.
  3. Expansive mood : the expression of one's feelings without limitation, often with exaggerated assessment of the person's interest or significance.
  4. Irritable mood : the feeling caused by the expression disturbed or angered easily.
  5. Labile mood : oscillation between euphoria and depression or angered.
  6. Elevated mood : atmosphere of confidence and pleasure ; a more cheerful mood than usual.
  7. Euphoria : elasi strong feeling of greatness.
  8. Ecstasy : a strong sense of excitement.
  9. Depression : feelings of sadness that psychopathological.
  10. Anhedonia : loss of interest and withdraw from all routine activities and fun, often accompanied by depression.
  11. Grief ( mourning ) : sadness in accordance with the real loss.
  12. Alexitimia : inability or difficulty in describing or being aware of one's emotions or mood.

Nursing Care Plan for Acute Psychotic


Definition of Acute Psychotic

Psychotic is mental disorder characterized by the inability of the individual to assess what actually happened, for example, there are hallucinations, delusions or chaotic behavior / weird.


Clinical Manifestations

The behavior exhibited by the patient are:
  1. Hearing voices no source.
  2. Belief or fear that weird / absurd.
  3. Confusion or disorientation.
  4. Changes in behavior ; be strange or scary as aloof, heightened scrutiny, threatening themselves, other people or the environment, to talk and laugh and get angry or hit for no reason.

Brief psychotic disorder symptoms always include at least one major psychotic symptoms, usually with sudden onset, but not always incorporate the overall pattern of symptoms found in schizophrenia. Some clinicians have observed that affective symptoms, confusion and concentration problems may be more often found in a brief psychotic disorder rather than a chronic psychotic disorder. Symptoms characteristic for brief psychotic disorder is an emotional change, clothing or bizarre behavior, yelling screaming or silent, and impaired memory for recent events occurred. Some of these symptoms are found in disorders that direct and clear diagnosis of delirium requires a complete organic inspection, although the result may be negative.

Mental status examination is usually present with severe psychotic agitation that may be associated with bizarre behavior, uncooperative, aggressive physical or verbal, irregular speak, shout or silence, labile mood or depression, suicide, kill thoughts or behavior, anxiety, hallucinations, delusions, disorientation, impaired attention, impaired concentration, memory impairment, and poor insight.

As in acute psychiatric patients, a history which is necessary to make the diagnosis may not be obtained only from the patient. Despite the presence of psychotic symptoms may be obvious, information on prodromal symptoms, previous episodes of a mood disorder, and a history of ingestion of a recently psychotomimetic substances may not be obtained from clinical interviews alone. In addition, clinical may not be able to obtain accurate information about the presence or absence of precipitating stressor.

The most obvious example is the originator of stresos major life events that can cause significant emotional anger in each person. The event is the death of a close family member and a heavy vehicle accidents. Some argue that the severity of clinical events should be considered in relation to the patient's life. Although this view has a reason, but it may expand the definition to include precipitating stressor events that are not associated with psychotic episodes. Other clinicians argue that stressors may be a sequence of events that cause stress are, rather than single events that give rise to stress the obvious. But the sum of the degree of stress caused by the sequence of events requires a degree of clinical judgment almost impossible.


Diagnosis

For a definite diagnosis of symptoms of acute psychotic disorders are as follows :
  1. Hallucinations (false sensory perceptions or imagined : for instance, no one heard a sound source or see something that no object).
  2. Delusions (strongly held idea that a real one and can not be accepted by social groups of patients, such as patients believe that they are poisoned by a neighbor, receiving messages from the television, or was observed / supervised by someone else).
  3. Agitation or bizarre behavior.
  4. Talks strange or chaotic (disorganization).
  5. Unstable emotional state and extreme (irritable).

Nursing Care Plan for Acute Psychotic

Maintaining patient safety and care of individuals, things to do :
  1. Family or friends should accompany the patient.
  2. Basic needs of patients are met (eg, eating, drinking, elimination, and hygiene).
  3. Be careful that the patient does not get injured.

Counseling patients and families :
  1. Help families identify aspects of the law relating to psychiatric treatment include: patient rights, obligations and responsibilities of the family in the treatment of patients.
  2. Assist patients and families to reduce the stress and contact with the stressor.
  3. Motivation of patients to perform activities of daily living after symptoms improve.

Nursing Care Plan for Crohn's Disease


Crohn's disease is an autoimmune disease characterized by inflammation of any part of the digestive tract starts from mouth to anus. Crohn's disease typically affects the ileum, the lower part of the small intestine. This condition occurs when the immune system reacts abnormally, attack bacteria, food, and other substances improperly, which causes the accumulation of white blood cells in the lining of the intestine.

Cause of Crohn 's disease is unknown. The study focused on three possible causes, namely :
1. Immune system dysfunction
2. Infection
3. Food

Although not found the presence of autoantibodies, regional enteritis is thought to be a hypersensitivity reaction or may be caused by an unknown infectious agent. These theories put forward because of the granulomatous lesions similar to lesions found in fungi and pulmonary tuberculosis. There are some interesting similarities between regional enteritis and ulcerative colitis. Both are inflammatory diseases, although the lesions is different. Both of these diseases have manifestations outside the digestive tract ; uveitis, arthritis and skin lesions were identical.

Crohn's disease that attacks the digestive system can cause a variety of complications, one of which is certainly disorders of the gut or digestive system. Crohn 's disease can cause a thickening or swelling of the intestinal wall, and this can cause blockage in the intestines. Finally, disturbed digestive system, intestines can not absorb nutrients from food, such as protein, vitamins, calories, and minerals.

Other complications that may arise as a result of Crohn 's disease is osteoporosis, anemia can cause fatigue, impaired liver function, cancer of the colon, toxic megacolon, kidney stone disease, or arthritis.

The main symptoms are diarrhea, abdominal pain, and weight loss . Often obtained malaise, loss of appetite, nausea, vomiting, and there may be subfebrile fever. Occur suddenly, can resemble obstruction and appendicitis. At regional enteritis, the onset of symptoms is usually hidden, with persistent abdominal pain and diarrhea that does not go away with defecation. Diarrhea occurred in 90 % of patients. Scar tissue and granuloma formation affects the ability of the intestine to transport the products of digestion upper intestine, through the lumen constriction, resulting in a cramping abdominal pain. Because the intestinal peristaltic stimulated by food, cramping pain occurs after eating. To avoid this cramping pain, patients tend to limit food intake, reducing the amount and types of food so that the normal nutritional needs are not met. The result is weight loss, malnutrition, and anemia secondary. In addition, the formation of ulcers in the lining membrane of the intestine and the place of inflammation, discharge will produce a constant irritant to the colon that are drawn from the thin intestine, swollen, which causes chronic diarrhea. Nutritional deficiencies may occur due to impaired absorption. The result is that the individual be thin because of inadequate food intake and fluid lost continuously. In some patients, inflamed bowel can be perforated and anal abscess formation, and intra-abdominal. Fever and leukocytosis. Abscesses, fistulas, and fissures are common. Clinical course and symptoms vary. In some patients there were periods of remission and exacerbation, while others follow the weight causes illness. Symptoms extends throughout the gastrointestinal tract and generally include joint problems (arthritis), skin lesions (erythema nodosum), ocular disorders (conjunctivitis), and oral ulcers.


Nursing Diagnosis for Crohn's Disease

1. Pain related to irritable initestinal, abdominal cramps and surgical response.
2. Fluid and Electrolyte imbalances related to discharge of excessive vomiting.
3. Imbalanced Nutrition Less Than Body Requirements related to the inadequate nutritional intake secondary to pain, stomach and intestinal inconveniences.
4. Risk for infection related to post- surgical wound.
5. Anxiety related to the prognosis of the disease and surgical plan.

Risk for Fluid Volume Excess and Activity Intolerance related to CHF


Nursing Diagnosis and Interventions for Congestive Heart Failure (CHF)

Nursing Diagnosis : Risk for Excess Fluid Volume ; extravascular related to decreased renal perfusion, increased sodium / water retention, increased hydrostatic pressure or a decrease in plasma protein (absorbing fluid in the interstitial area / tissue).

Goal :
Fluid volume balance can be maintained.

Outcomes :
  • Maintaining fluid balance as evidenced by blood pressure within normal limits, no peripheral venous distention / vein and dependent edema, pulmonary clean and ideal weight.

Intervention :
  • Measure input / output, note the decline, expenditure, the nature of concentration, calculate fluid balance.
  • Observation of dependent edema.
  • Measure body weight per day.
  • Maintain fluid intake in cardiovascular tolerance.
  • Collaboration: the low-sodium diet, give diuretics.
  • Assess the JVP after diuretic therapy.
  • Monitor CVP and blood pressure.


Nursing Diagnosis : Activity Intolerance related to imbalance between myocardial oxygen supply and demand, the presence of ischemic / necrotic myocardial tissue.

possibility evidenced by :
  • cardiac frequency interference,
  • occurrence of dysrhythmias and general weakness.

Goal :
There was an increase in the client's activity tolerance after nursing actions implemented.

outcomes :
  • Heart rate ; 60-100 X / min,
  • Blood pressure ; 120/80 mmHg

Intervention :
  • Record the heart rate , rhythm and change in BP during and after activity.
  • Increase rest (in bed).
  • Limit activity on the basis of pain and provide sensory activities that are not heavy.
  • Describe the pattern of a gradual increase in the level of activity, for example ; get up from the chair in the absence of pain, ambulation and rest for 1 hour after eating.

Nursing Diagnosis

Nursing Diagnosis

NANDA NURSING DIAGNOSIS

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