Nursing Diagnosis and Nursing Intervention

Acute Pain related to Cellulitis

Nursing Care Plan for Cellulitis

Cellulitis is an infection by Staphylococcus, Streptococcus, or by both of them in the deepest layers of the skin. Bacteria can enter the body through the other parts of the skin of a cut, scratch, or bite. Usually if the skin is infected, affected only the top layer and will disappear on their own with proper care. But in cellulitis, skin tissue becomes infected parts in red, hot, inflamed and painful. Cellulitis usually occurs on the face and lower legs.

While according to Neville, Oral and Maxillofacial Pathology, explains that the term cellulitis used an oedematous deployment of acute inflammation on the surface of the soft tissues and is diffuse. Cellulitis can occur in all places where there is soft tissue and loose connective tissue, especially on the face and neck, because usually in the area of defense against infection is less than perfect.

The main causes of facial cellulitis is Staphylococcus aureus and Streptococcus b- hemolyticus, whereas Staphylococcus epidermidis is a normal inhabitant of the skin and rarely fight infections. Pyoderma predisposing factor is the lack of hygiene, immune deficiencies, and other diseases have been found in the skin.

Cellulitis are not contagious, usually begins as a small, inflamed, pain, swelling, heat, and redness of the skin. When the milking area began to spread, the child will feel pain and discomfort, fever, and can be accompanied by chills and sweating. Swollen lymph nodes in the folds are sometimes found on the nearby skin infections.

Nursing Diagnosis and Interventions :

Acute Pain related to local inflammatory response of subcutaneous tissue.

Goal : The client expressed pain decreased after nursing care.

Expected outcomes :
  • Stable pain scale (0-3).
  • Showed no pain / controlled.
  • Looks relaxed, able to sleep / rest and participate in activities according to ability.
  • Following the recommended pharmacological program.

Intervention :

1. Observation pain scale (0-10), the characteristics of pain, and pain location.
Rational : assist in determining the need for pain management, and program effectiveness.

2. Let the patient take a comfortable position and increase bed rest as indicated.
Rational : to limit the pain.

3. Give a gentle massage.
Rational : increase relaxation / reduce muscle tension.

4. Encourage the use of stress management techniques, such as progressive relaxation, therapeutic touch, biofeedback, visualization, guidance imagination, self hypnosis, and breath control.
Rational : increase relaxation, gives a sense of control, and may improve coping skills.


5. Give the medicine before the activity / exercise is planned, according to the instructions.
Rational : increase relaxation, reduce muscle tension / spasm, easy to participate in therapy.

6. Apply ice or a cold pack if necessary.
Rational : the cold can relieve pain and swelling during the acute period.

Risk for Fluid Volume Deficit related to Low Birth Weight

Nursing Care Plan for Low Birth Weight

Nursing Diagnosis : Risk for Fluid Volume Deficit age and extreme weight, excessive fluid loss (thin skin), less fat layer, immature kidney / failure to concentrate urine.

Goal: liquid fulfilled

Expected outcomes:
  • Free of signs of dehydration.
  • Shows the weight gain of 20-30 grams / day.

Interventions :

  • Compare the input and output of urine, every shift and balance each periodic cumulative 24 hours.
  • Monitor the specific gravity of each finished urinating or every 2-4 hours to inspire urine from diapers when the baby can not stand the reservoir bag urine.
  • Evaluation of skin turgor, mucous membranes, and the state of the anterior fontanelle.
  • Monitor blood pressure, pulse, and mean arterial pressure (TAR).
  • Monitor laboratory examination in accordance with the indications; Ht.
  • Give parenteral infusion.
  • Give a blood transfusion.

Rationale :
  • Output should be 1-3 ml / kg / h, while the need for fluid therapy is approximately 80-100 ml / kg / day on the first day, increased to 120-140 ml / kg / day on the third day postpartum. Blood sampling for tests lead to decreased levels of hemoglobin / hematocrit.
  • Although renal immaturity and inconvenience to concentrate urine, usually resulting in a low specific gravity in preterm infants (range normal1,006-1,013). Low levels indicates excessive fluid volume and content of greater than 1.013 indicates the inability of fluid intake and dehydration.
  • Loss or minimal fluid shifts can quickly lead to dehydration, visible by poor skin turgor, dry mucous membranes, and sunken fontanelle.
  • Losing 25% of blood volume resulting in shock, with TAR 25 mmHg indicates hypotension.
  • Dehydration increases hematocrit levels 45-53% above normal serum potassium.
  • Hypoglycemia can occur due to loss through diarrhea or vomiting nasogastric tube.
  • The replacement of body fluids increase the volume of blood, helps restore vasoconstriction due to hypoxia, acidosis, and right-to-left shunt through the PDA, and has helped in reducing complications necrotizing enterocolitis, and bronchopulmonary dysplasia.
  • It may be necessary to maintain the levels of hematocrit / hemoglobin optimal and replace blood loss.

Ineffective Breathing Pattern related to Low Birth Weight

Ineffective Breathing Pattern related to Low Birth Weight
Nursing Care Plan for Low Birth Weight

Nursing Diagnosis :  Ineffective Breathing Pattern

According Manuaba (2002) since 1961 WHO replace the term premature with low birth weight (LBW) as they realized that not all babies born weighing less than 2500 grams at birth is not premature baby, then according Pantiawati (2009), LBW is a baby with birth weight less than 2500 grams. Meanwhile, according Proverawati (2010) LBW is babies born weighing less than 2500 grams regardless of pregnancy, in line with the opinions Prawiroharjo (2011) LBW is newborn birth weight less than 2500 (up to 2499 grams).

According Proverawati (2010), Clinical / LBW Infants characteristics:
  • Weight less than 2500 grams.
  • Length of less than 45 cm.
  • Chest circumference less than 30 cm.
  • Head circumference less than 33 cm.
  • Thin subcutaneous fat tissue or less.
  • Gestational age less than 37 weeks.
  • Larger heads.
  • Transparent thin skin, lanugo hair a lot, less fat.
  • Cartilage earlobe, rudimentary growth.
  • Weak hypotonic muscle is a muscle that is no active movement of the arms and elbows.
  • Irregular breathing can occur apnea.
  • Extremities: abduction of the thigh, the knee / leg flexion-straight, heel shiny, smooth soles.
  • Head is not able to erect, yet nerve function or ineffective and weak tears.
  • Breathing 40-50 times / min and pulse 100-140 beats / min.

Nursing Diagnosis for Low Birth Weight : Ineffective breathing pattern related to the immaturity of the respiratory center, the limitations of muscle growth or decline in muscle weakness and metabolic imbalance.

Goal: Patterns breath back effectively.

Expected outcomes:
Neonates will maintain periodic breathing patterns.
Pink mucous membranes.

Nursing Interventions :

Assess the frequency and pattern of breathing, note the presence of apnea and cardiac frequency changes.
Suction the airway as needed.
Place the baby in the abdomen or supine position with a rolled diaper under the shoulder to produce hyperextension.
Review the history of the mother to drugs that would aggravate respiratory depression in infants.

Monitor laboratory tests as indicated.
Give oxygen as indicated.
Give medications as indicated.

Rationale :

Help in distinguishing normal breathing rotation period of true apnea attacks, especially common in the 30th week of gestation.
Eliminate mucus that clogs the airways.
This position facilitates breathing and decrease episodes of apnea, especially if found any hypoxia, metabolic acidosis or hypercapnia.
Magnesium sulfate and narcotics suppress the respiratory center and CNS activity.
Hypoxia, metabolic acidosis, hypercapnia, hypoglycemia, hypocalcemia and sepsis aggravate apnea attacks.
Improvement of oxygen and carbon dioxide levels can improve respiratory function.

Nursing Interventions for Bone Cancer

Definition of bone cancer is cancer that occurs in the bone. Bone cancer can occur in any bone in the body, such as cancer of the spine, etc., but most often affects the arm and leg bones. There are several types of bone cancer. Some types of bone cancer occurs primarily in children, while others affect mostly adults.

Symptoms of Bone Cancer

Characteristic feature of bone cancer or bone cancer symptoms include:
  • Bone pain.
  • Swelling and pain near the affected area.
  • Fracture.
  • Fatigue.
  • Weight loss is not desired.

Types of Bone Cancer

Bone cancer is divided into separate types based on the type of cell where the cancer started. The most common type of bone cancer include:
  • Osteosarcoma. Osteosarcoma begins on bone cells. Osteosarcoma occurs most often in children and young adults.
  • Chondrosarcoma. Chondrosarcoma begins in the cartilage cells are normally found in the bone ends. Chondrosarcoma most commonly affects older adults.
  • Ewing's Sarcoma. It is not clear where ewing sarcoma begins. Ewing's sarcoma is believed that to begin in nerve tissue in the bone. Ewing's sarcoma occurs most often in children and young adults.

Nursing Interventions for Bone Cancer

1). Pain management
Psychological pain management techniques (deep breath relaxation techniques, visualization, and guided imagery) and pharmacological (providing analgesic).

2). Teach effective coping mechanisms
Motivation clients and families to express their feelings, and give moral support and encourage families to consult a psychologist or clergy.

3). Provide adequate nutrition
Decreased appetite, nausea, vomiting often occur as a side effect of chemotherapy and radiation, so it should be given adequate nutrition. Antiemetic and relaxation techniques can reduce gastrointestinal reactions. Parenteral nutrition can be carried out in accordance with the indications of the doctor.

4). Health education
Patients and families are given health education on the likelihood of complications, treatment programs, and wound care techniques at home (Smeltzer. 2001: 2350).

5) If necessary; traction, Traction Treatment Principles
  • Provide comfort measures (eg frequently change position, back massage) and therapeutic activity.
  • Give the drug as an indication of examples; analgesic muscle relaxant.
  • Give local heating as indicated.
  • Give strength in early bandage / replacement in accordance with the indications, use aseptic technique correctly.
  • Keep linen remains dry, free of wrinkles.
  • Encourage the client to use loose cotton clothing.
  • Encourage the client to use stress management, for example: guided imagery, deep breathing.
  • Assess the degree of immobilization produced.
  • Identification signs or symptoms that require medical evaluation, eg edema, erythema.
Copyright © Nursing Diagnosis Intervention. All rights reserved. Template by CB | Published By Kaizen Template | GWFL | KThemes