Nursing Diagnosis and Nursing Intervention


Social Isolation related to Schizophrenia

Nursing Care Plan for Schizophrenia

Nursing Diagnosis : Social Isolation
related to :
  • lack of confidence to others.
  • freaking out.
  • regression to earlier developmental stages.
  • delusions.
  • difficult to interact with others in the past.
  • weak ego development.
  • repression of fear.

Defining characteristics:
  • Alone in the room.
  • Not communicate, withdraw, do not make eye contact (mutism, autism).
  • Sad, flat affect.
  • Attention and actions that are inconsistent with developmental age.
  • Thinking about things according to his own thoughts, actions are repetitive and meaningless.
  • Approaching nurses to interact, but then refused to respond to the nurse to self-acceptance.
  • Expressing feelings of rejection or loneliness to others.


Planning:

General Purpose:
  • The patient can voluntarily spend time with other patients and nurses in the group's activities.

Special purpose:
  • The patient already included in the activity therapy was accompanied by a nurse to believe in one week.

Expected outcomes:
  • The patient may demonstrate a desire to socialize with other people.
  • The patient can follow the group activity without prompting.
  • The patient did approach the interaction with others in a way that is appropriate / acceptable.


Intervention:

1. Show the acceptance by conducting frequent contacts, but brief.
rational:
Acceptance of others will improve the patient's self-esteem and facilitates a sense of trust in others.

2. Show a positive reinforcement to the patient.
rational:
Make the patient feel that would be a useful.

3. Accompany the patient to show support for group activities that may be the case that scary or difficult for the patient.
rational:
The presence of someone who believed would provide a sense of security to the patient.

4. Honest and keep all appointments.
rational:
Honesty and a sense of need raises a trusting relationship.

5. Orient the patient at the time, people, places, as needed.

6. Be careful with the touch. Let the patient got an extra room and the opportunity to leave the room if the patient becomes so anxiety.
rational:
The patients who suspect may be receptive to touch as a body language that suggests the threat.

7. Give the drugs, according the patient's treatment program. Monitor the effectiveness and side effects of drugs.
rational:
Medications help to reduce the symptoms of psychosis in a person, thus facilitating interaction with other people.

8. Discuss with the patient signs of increased anxiety and techniques to cut response. (Eg, relaxation exercises, "stop thinking").
rational:
Maladaptive behavior such as withdrawing and suspicious manifested during an increase in anxiety.

9. Give recognition and appreciation without prompting the patient can interact with others.
rational:
Reinforcement will increase the patient's self-esteem and encourage the repetition of such behavior.

Disturbed Sensory Perception (visual) related to Glaucoma


Nursing Care Plan for Glaucoma

Glaucoma is a group of eye disorders characterized by increased intraocular pressure. (Barbara C. Long, 2000: 262)

Glaucoma is an eye condition that is usually caused by an abnormal increase in intraocular pressure (up to more than 20 mmHg). (Elizabeth J.Corwin, 2009: 382)


Classification

Glaucoma is divided into; primary glaucoma, secondary, and congenital.

1. Primary Glaucoma

In primary glaucoma has no known cause, obtained form:
  • Closed angle glaucoma, acute congestive glaucoma.
  • Open angle glaucoma, chronic simple glaucoma.

2. Secondary Glaucoma

Secondary glaucoma occurs as a result of other diseases in the eye, caused by:
a. Lens aberration.
  • Luxation.
  • Swelling (intumescent).
  • Phacolytic.
b. abnormalities of the uvea
  • Uveitis.
  • Tumors.
c. Trauma
  • Bleeding in the anterior chamber. (Hyphema).
  • Perforation of the cornea and iris prolapse, which caused leucoma adherent.
d. Surgery
  • Anterior chamber are not quickly formed after cataract surgery.
e. Other causes of secondary glaucoma
  • Rubeosis iridis (due to central retinal vein thrombosis).
  • Excessive use of topical corticosteroids.

3. Congenital glaucoma
  • Primary congenital glaucoma or infantile glaucoma. (Buftalmos, hidroftalmos).
  • Glaucoma concerned with other congenital abnormalities.

4. Absolute Glaucoma
  • Final state of a glaucoma, ie with total blindness and eye pain.
(Sidarta Ilyas, 2002: 240-241)


Clinical Manifestations
  1. Pain in the eye and surrounding areas (orbital, head, teeth, ears).
  2. View of foggy, Seeing rainbows around lights.
  3. Nausea, vomiting, sweating.
  4. Red eye, conjunctival hyperemia, and ciliary.
  5. Decreased visual acuity.
  6. Corneal edema.
  7. Shallow anterior chamber (may not be found in open-angle glaucoma).
  8. Pupil wide oval, no reflex to light.
  9. IOP increases.
(Anas Tamsuri, 2010: 74-75)


Nursing Diagnosis : Disturbed Sensory Perception (visual) related to decrease in visual acuity and clarity of vision.

Subjective:
  • Stated vision blurred, indistinct, decreased vision area.
Objective:
  • Decreased visual field examination.
  • Decreased ability to identify the environment (objects, people, places)
Goal:
The client reported a greater ability to process visual stimuli and communicate the visual changes.

Expected outcomes:
  • The client identifies the factors that affect visual function.
  • The client identifies and shows patterns of alternatives to improve the visual stimuli reception.


Interventions :

1.Assess the client's visual acuity.
2. Approach the clients of the healthy side.
3. Identification of alternatives to optimize the stimulus source.
4. Adjust the environment to optimize vision:
  • Orient the client to the ward.
  • Place the tool that is often used near a client or on the sides of the eyes healthier.
  • Provide sufficient lighting.
  • Put in place a fixed tool.
  • Avoid glare.
5. Encourage the use of alternative acceptable environmental stimuli: auditory, tactile.


Rationale :

1. Identify the client visual capabilities.
2. Provide sensory stimulation, reducing the sense of isolation / alienation.
3. Giving sight accuracy and maintenance.
4. Improving the ability of sensory perception.
5. Improving the ability of response to environmental stimuli.

Knowledge Deficit related to Diabetic Foot Ulcers


Nursing Care Plan for Diabetic Foot Ulcers

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

Goal: The patient receive clear and accurate information about the disease.

Expected outcomes:
  • The patient know about the disease, diet, care and treatment and may explain the return if asked.
  • The patient can perform self-care based on the knowledge acquired.

Interventions:

1. Assess the level of knowledge of the patient / family about the disease of diabetes and gangrene.
Rationale: To provide information to patients / families, nurses need to know the extent to which 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 by using words and phrases that can understand the patient as the patient's level of education.

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

4. Explain the procedure to be performed, the benefits to the patient and the patient engage in it.
Rationale: With the explanations and participate directly in the action taken, the patient will be more cooperative and reduced anxiety.

5. Use pictures to give an explanation (if there is / possible).
Rational: images may help to remember the explanation has been given.

Ineffective Tissue perfusion related to Diabetic Foot Ulcers

Nursing Care Plan for Diabetic Foot Ulcers

Ulcers are open sores on the skin or mucous membrane surface and the ulcer is extensive tissue death and accompanied invasive saprophyte bacteria. The existence of the saprophyte bacteria cause ulcers smelling, diabetic ulcers is also one of the symptoms and the clinical course of the disease diabetes mellitus with peripheral neuropathy. (Andyagreeni, 2010).

Diabetic ulcers are chronic complications of diabetes mellitus as a major cause of morbidity, mortality and disability in patients with diabetes. High LDL levels play an important role for the occurrence of diabetic ulcers through the formation of atherosclerotic plaque in the walls of blood vessels, (zaidah 2005).

Diabetic foot ulcers are the complications associated with morbidity from diabetes mellitus. Diabetic foot ulcers are serious complications due to diabetes. (Andyagreeni, 2010).



Nursing Care Plan for Diabetic Foot Ulcers

Nursing Diagnosis : Ineffective Tissue perfusion related to weakening / decrease in blood flow to the area of gangrene due to obstruction of blood vessels.

Goal: maintain peripheral circulation remained normal.

Expected outcomes:
  • Palpable peripheral pulses were strong and regular.
  • The color of the skin around the wound; not pale / cyanosis.
  • The skin around the wound felt warm.
  • Edema does not occur and the wound is not getting worse.
  • Sensory and motor improves.

Interventions:

1. Instruct the patient to mobilize.
Rational: the mobilization improves blood circulation.

2. Teach about the factors that can increase blood flow: Elevate the patient's leg is slightly lower than the heart (elevation position at rest), avoid crossing legs, avoid tight bandage, avoid the use of cushions, behind the knees and so on.
Rational: increase blood flow back so there is no edema.

3. Teach about the modification of risk factors such as:
Avoid high-cholesterol diet, relaxation techniques, stop smoking, and drug use vasoconstriction.
Rational: high cholesterol can accelerate the onset of atherosclerosis, smoking can cause vasoconstriction of blood vessels, relaxation to reduce the effects of stress.

4. Cooperation with other health care team in the delivery of vasodilators, checks blood sugar regularly and oxygen therapy.
Rational: vasodilator administration will increase the dilation of blood vessels and tissue perfusion can be improved, while the regular blood sugar checks can track the progress and state of the patient.

Nursing Diagnosis

Nursing Diagnosis

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