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.

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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.

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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.

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Nursing Care Plan for Chickenpox

Nursing Diagnosis for Chickenpox

Chickenpox is an infectious disease caused by the varicella-zoster virus infection. The disease is transmitted aerogen.


Incubation time

When exposed to the plague within 2 to 3 weeks. this can be characterized by the body feels hot but not fever.


Symptoms

Initially, patients may feel a slight fever, runny nose, quickly feel tired, lethargic, and weak. These symptoms are typical for a viral infection. In more severe cases, you can also get joint pain, headache and dizziness. A few days later occurred the redness of the skin that is small for the first time found around the chest and abdomen or buttocks, followed arise member and facial movements.

Redness of the skin is then turned into the eject containing liquid with a thin wall. This rash may feel a bit of pain or itching that can be accidentally hit. If recoil is left then immediately dried up scab and it will be missed and leave spots on darker skin (hyperpigmentation). These spots will gradually fade until some time later, they will not leave the container again.

Another case where the eject chickenpox is broken. Krusta soon to be formed over the dry longer. These conditions facilitate bacterial infection occurs on former scratch now. after drying container will eliminate chickenpox earlier in containers. Especially if patients are adults or young adults, the former will be more difficult chickenpox disappear.


Quarantine time

For 5 days after the rash appears and until all starting blisters have scab. During quarantine sufferers should still shower as usual, because of the germs that are on the skin will be menginfeksi skin is exposed to chicken pox. To avoid any potential loss of confidential scar should avoid breakage eject chickenpox. When drying the body after a bath should not rub with the towel too hard. To avoid irritation, should be given containing menthol powder talk to reduce friction that occurs on the skin so that the skin is more irritated. For having sensitive skin can also use the powder salycil talk that does not contain bulbs. Make sure you are always consuming nutritious food to accelerate the healing process itself. Consumption of fruits that contain vitamin C such as guava and red tomato juice can be made.


Prevention

Immunizations are available for children older than 12 months. Vaccination is also recommended for people over the age of 12 years who do not have immunity, or those who have never been exposed to this disease, because adults affected with this disease, usually more severe and can sometimes be unconscious. For those who were over the age of 50 years should be vaccinated again.


Nursing Diagnosis

1. Hypertermia related to the disease.
2. Impaired Skin Integrity related to mechanical factors (eg stress, tear, friction)
3. Disturbed Body Image related to lesions on the skin.
4. Deficient Knowledge: about the condition and treatment needs.
5. Risk for Infection related to damage skin tissue.

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Sample of Nursing Care Plan for Wandering

Wandering Definitions:

Moving from place to place without a fixed plan; roaming; rambling: wandering tourists.

Related factors:

• Cognitive impairment (disorientation, difficulty remembering and memory).
• Emotional (depression).
• Excessive stimuli from the environment.
• Lasts all day.

Objective data:
A woman, 62-year-old was found wandering, not be able to remember the people (neighbors, saleswoman) and the events that happened in the previous weeks.

Subjective data:
The patient reported that the stress because she was arguing with her husband. She said that she did not plan wandering. Only instinctively move from one place to another.


NOC

1. Safe Wandering
Definition: Safe, socially acceptable with no visible that cognitively impaired.

Indicators:

• The patient is able to move without hurting themselves (1-5).
• The Patient were able to demonstrate that the activity has a goal (1-5).
• The patient wants to go home (1-5).

2. Acute confusion level
Definition: The severity of disturbances in consciousness and cognition that develops in a short period of time.

Indicators:

• Patients did not experience disorientation place (1-5)
• Patients did not experience disorientation people (1-5)
• Patients experienced a decline in memory impairment (1-5)

3. Memory
Definition:
The ability to restore cognitive function and reported previously stored information.

Indicators:

• Given the close information accurately (1-5)
• Given the information just accurately (1-5)
• Given the information that the information is accurate (1-5)

NIC

1. Reality Orientation
Definition: introduce / increase patient awareness regarding personal identity, time and the environment.

Activities:

• Using a consistent approach when interacting with patients.
• Inform patients about the people, places and times as needed.
• Preventing patients frustrated by giving questions related to orientation can not afford missed.
• Provide a physical environment that remains and planned daily routine.
• Approach the patient with slowly and from the front.
• Using a calm approach and not rush when interacting with patients.
• Speak slowly, clearly and corresponding volume in patients.

2. Medication Management
Definition: Facilitation of safe and effective use of prescription and over the counter drugs.

Activities:

• Determine and regulate the drug is needed in accordance with the protocol.
• Monitor the effectiveness of treatment modalities.
• Monitor patient adherence to treatment regimens.

3. Family Involvement Promotion
Definition: Facilitating family participation in the emotional and physical care of patients.

Activities:

• Identification with family members about the patient's difficulty coping.
• Inform family members about the factors that may increase the patient's condition.
• Encourage family members to keep or maintain a good relationship with the family.

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Nursing Care Plan for Mastoiditis

Mastoiditis is the result of an infection that extends to the air cells of the skull behind the ear.



Causes of Mastoiditis

Acute mastoiditis:

• Haemophilus influenzae.
• Streptococcus pneumoniae.
• Streptococcus pyogenes.
• Moraxella catarrhalis.
• Staphylococcus aureus, including methicillin-resistant Staphylococcus aureus infection (MRSA).

Chronic mastoiditis:

• Staphylococcus aureus, including MRSA.
• Infection is often polymicrobial.
• Gram-negative organisms such as Escherichia coli, Proteus, or Pseudomonas.
• Anaerobic bacteria: Peptostreptococcus species, anaerobic Gram-negative bacilli (ie, pigmented Prevotella, Porphyromonas, and Bacteroides species) and Fusobacterium species.
• Mycobacterium tuberculosis, nontuberculous mycobacteria, and Mycobacterium bovis are rare causes.

Symptoms of Mastoiditis

• Ear pain or discomfort
• Drainage from the ear
• Headache
• Fever, may be high or suddenly increase
• Redness of the ear or behind the ear
• Hearing loss
• Swelling behind ear, may cause ear to stick out

Nursing Diagnosis for Mastoiditis

1. Acute pain related to inflammation process.
2. Disturbed Sensory perception related to obstruction, infection of the middle ear or auditory nerve damage.
3. Anxiety related to the inability to communicate.
4. Risk for injury related to vertigo and a decrease in body balance

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Nursing Care Plan for Cerebral Palsy

Assessment

1. Assess the mother's pregnancy history
2. Assess history of childbirth
3. Identification of children who are at risk
4. Assess the child irritable, difficulty in eating / swallowing, delayed development of normal children, the development of less movement, abnormal posture, lack of movement development, abnormal posture, persistent infant reflexes, ataxic, lack of muscle tone.
5. Monitor response to child's play
6. Assess intellectual functioning
7. No muscle coordination when performing movement (loss of balance)
8. Stiff muscles and exaggerated reflexes (spasticas)
9. Difficulty chewing, swallowing and sucking, and difficulty speaking.
10. body shaking
11. Difficulty moving exactly like menulus or pressing a button.
12. Children with cerebral palsy may have additional problems, including the following: seizures, problems with vision and hearing as well as in speaking, there are learning disabilities and behavioral disorders, mental retardation, problems related to respiratory problems, problems in defecation and waste little water, and there are re-shape abnormalities such as scoliosis.
13. Past medical history: premature birth, and birth trauma.
14. History of present illness: muscle weakness, mental retardation, severe disorders-hypotonia, Throwing / Suction eating, impaired speech / voice, visual and hearing.

Subjective data :

1. Parents say that when pregnant mothers experienced tooplasmosis, their children's growth rather late.
2. Parents say son can not walk seendiri, can not feed themselves, can not brush your teeth with help.
3. Parents also say that children can not do the things kids his age do.
4. Parents feel the burden of caring for their children and embarrassed by her condition. Parents worried about their future.

Objective data :

1. Test results showed the body feel warm.
2. Sweat a lot
3. There are involuntary movements (not coordinated)
4. posture opistotonik
5. Children difficulty to eat
6. Often ceguken, and irritabel.

Nursing Care Plan for Cerebral Palsy - Nursing Diagnosis

1. Hypertermia
2. Risk for injury
3. Imbalanced Nutrition, Less Than Body Requirements
4. Impaired verbal communication
5. Activity intolerance
6. Delayed growth and development
7. Knowledge deficit
8. Ineffective breathing pattern

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Nursing Care Plans: Diagnoses, Interventions, and Outcomes

The bestselling nursing care planning book on the market, Nursing Care Plans: Diagnoses, Interventions, and Outcomes, 8th Edition covers the most common medical-surgical nursing diagnoses and clinical problems seen in adults. It includes 217 care plans, each reflecting the latest evidence and best practice guidelines. NEW to this edition are 13 new care plans and two new chapters including care plans that address health promotion and risk factor management along with basic nursing concepts that apply to multiple body systems. Written by expert nursing educators Meg Gulanick and Judith Myers, this reference functions as two books in one, with 147 disorder-specific and health management nursing care plans and 70 nursing diagnosis care plans to use as starting points in creating individualized care plans.

Read More : Nursing Care Plans: Diagnoses, Interventions, and Outcomes, 8e

• 217 care plans --- more than in any other nursing care planning book.
• 70 nursing diagnosis care plans include the most common/important NANDA-I nursing diagnoses, providing the building blocks for you to create your own individualized care plans for your own patients.
• 147 disorders and health promotion care plans cover virtually every common medical-surgical condition, organized by body system.
• Prioritized care planning guidance organizes care plans from actual to risk diagnoses, from general to specific interventions, and from independent to collaborative interventions.
• Nursing diagnosis care plans format includes a definition and explanation of the diagnosis, related factors, defining characteristics, expected outcomes, related NOC outcomes and NIC interventions, ongoing assessment, therapeutic interventions, and education/continuity of care.
• Disorders care plans format includes synonyms for the disorder (for easier cross referencing), an explanation of the diagnosis, common related factors, defining characteristics, expected outcomes, NOC outcomes and NIC interventions, ongoing assessment, and therapeutic interventions.
• Icons differentiate independent and collaborative nursing interventions.
• Student resources on the Evolve companion website include 36 of the book's care plans - 5 nursing diagnosis care plans and 31 disorders care plans.
• Three NEW nursing diagnosis care plans include Risk for Electrolyte Imbalance, Risk for Unstable Blood Glucose Level, and Risk for Bleeding.
• Six NEW health promotion/risk factor management care plans include Readiness for Engaging in a Regular Physical Activity Program, Readiness for Enhanced Nutrition, Readiness for Enhanced Sleep, Readiness for Smoking Cessation, Readiness for Managing Stress, and Readiness for Weight Management.
• Four NEW disorders care plans include Surgical Experience: Preoperative and Postoperative Care, Atrial Fibrillation, Bariatric Surgery, and Gastroenteritis.
• NEW Health Promotion and Risk Factor Management Care Plans chapter emphasizes the importance of preventive care and teaching for self-management.
• NEW Basic Nursing Concepts Care Plans chapter focuses on concepts that apply to disorders found in multiple body systems.
• UPDATED care plans ensure consistency with the latest U.S. National Patient Safety Goals and other evidence-based national treatment guidelines.
• The latest NANDA-I taxonomy keeps you current with 2012-2014 NANDA-I nursing diagnoses, related factors, and defining characteristics.
• Enhanced rationales include explanations for nursing interventions to help you better understand what the nurse does and why.

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