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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Pleural Effusion - Functional Health Pattern Assessment

Functional Health Pattern Assessment



1. Health Perception and Management

The presence of medical treatment and hospitalization affect change perceptions about health, but also raises sometimes wrong perception of health care. The possibility of a history of smoking, drinking alcohol and drug use may be a predisposing factor of disease.


2. Nutritional metabolic pattern

In the study of nutrition and metabolic patterns, we need to take measurements of height and weight to determine the nutritional status of the patient, as well as eating habits need to be asked and drinking before and during hospital admission of patients with pleural effusion will decrease appetite and shortness of breath as a result of emphasis on the structure of the abdomen. Increased metabolism will occur as a result of the disease process. patients with pleural effusion generally weak state.


3. Elimination pattern

In the assessment of the pattern of elimination have any questions about illusion and defecation habits before and after hospital admission. Because the patient's general condition is weak, the patient will be much bed rest so will cause constipation, digestive apart due to the structure of the abdomen causing a decrease in the peristaltic muscles degestivus tract.


4. Activity exercise pattern

Due to shortness of breath, tissue oxygen demand will be less fulfilled and the patient will quickly experience fatigue on minimal exertion. Besides, patients will also reduce its activity due to a chest pain. And to meet the needs of the ADL, the needs of patients assisted by nurses and patients' families.


5. Sleep rest pattern

The presence of chest pain, shortness of breath and an increase in body temperature will affect the fulfillment of the needs of sleep and rest, other than that due to changes in the environmental conditions of a quiet home environment to the hospital setting, where many people are walking around, noisy and so forth.


6. Cognitive-perceptual pattern

As a result of illness, the patient will experience a direct role changes, eg a housewife patient, the patient can not function as a mother who must care for their children, taking care of her husband. In addition, the patient's role in society is also changing and all that affects the patient's interpersonal relationships.


7. Self perception/self concept pattern

Patients' perception of him will change. Patients who are otherwise healthy, a sudden onset of pain, shortness of breath, chest pain. As a layman, the patient may be assumed that the disease is dangerous and deadly disease. In this case the patient may have lost a positive image of him.


8. Role-Relationship Pattern

Sensory function of patients did not change, as well as thought processes.


9. Sexuality-Reproductive Pattern

Sexual needs of the patient in this case sexual intercourse will be disturbed for a while because the patient was in the hospital and his physical condition is still weak.


10. Coping-stress tolerance

For patients who do not know the disease process may be experiencing stress and many patients will ask nurses and doctors who cared for him or anyone who may know more about the disease considered.


11. Value-Belief pattern

As a religion, a patient will be praying to God.

Anxiety related to Pleural Effusion

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Anxiety related to Pleural Effusion

Pleural effusion is an abnormal amount of fluid around the lung. Pleural effusion is excess fluid that accumulates between the two pleural layers, the fluid-filled space that surrounds the lungs.

Some of the more common causes are:

• Congestive heart failure
• Pneumonia
• Liver disease (cirrhosis)
• End-stage renal disease
• Nephrotic syndrome
• Cancer
• Pulmonary embolism
• Lupus and other autoimmune conditions

Symptoms of pleural effusions

• Shortness of breath
• Chest pain, especially on breathing in deeply (pleurisy, or pleuritic pain)
• Fever
• Cough

Nursing Diagnosis for Pleural Effusion : Anxiety or fear in relation to the threat of death imaginable (inability to breathe).

Goal : Patient is able to understand and accept the situation so there is no anxiety .

Outcomes:

• Able to breathe normally, able to adapt to the situation.
• Client's non-verbal response seemed more relaxed and at ease , the breath regularly with a frequency of 16-24 times per minute , pulse 80-90 times per minute.

Interventions :

1. Provide a pleasant position for the patient . Usually with a semi -Fowler.

2. Explain about the disease and diagnosis.
Rationale: The patient is able to receive and understand the circumstances that might be used in the treatment of co-operation.

3. Teach relaxation techniques.
Rationale : Reduce muscle tension and anxiety.

4. Aids in finding the source of the existing coping.
Rational Utilization of existing resources constructively coping very useful in overcoming stress.

5. Maintain a trusting relationship between nurse and patient.
Rationale : The relationship of mutual trust help the therapeutic process.

6. Assess the factors that cause anxiety.
Rationale : Appropriate action is necessary to address the problems faced by clients and build trust in reducing anxiety.

7. Aids patients recognize and acknowledge a sense of anxiety.
Rationale : Anxiety is an emotion that effect when they are well identified, disturbing feelings be known.

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Social Isolation: withdrawal related to Low Self-esteem

Nursing Care Plan for Hallucination

Nursing Diagnosis : Social Isolation: withdrawal related to Low Self-esteem

Goal : Patients can connect with other people in stages .

Outcomes:

• Patients can mention coping can be used .
• Patients can mention the effectiveness of coping used .
• Patients are able to begin to evaluate themselves .
• patients are able to make a realistic plan in accordance with the existing capabilities at him .
• Patients are responsible for any action taken in accordance with the plan to .

Intervention :

1. Encourage the patient to mention the positive aspects in him physically .
2. Discuss with the patient about his expectations .
3. Discuss with patients who stand out for their skills at home and in the hospital .
4. Give compliments .
5. Identify the problems being faced by patients
6. Discuss coping used by the patient .
7. Discuss effective coping strategies for patients .
8. Stressor identification with the patient and how the patient penialian to stressors .
9. Explain that the patient confidence to stressors affect the mind and behavior .
10. Together with the patient identification illustrate the belief that the goal is not realistic .
11. Together with the identification of patients coping strengths and resources owned
12. Show me the concept of success and failure with a suitable perception .
13. Discuss adaptive and maladaptive coping .
14. Discuss and losses due to maladaptive coping responses .
15. Help the patient to understand that the only patients who can transform themselves not others
16. Encourage the patient to formulate plans / objectives themselves ( not a nurse ) .
17. Discuss the consequences and realities of planning / goal .
18. Help the patient to clearly menetpkan changes expected .
19. Encourage the patient to begin a new experience to develop according to the existing potential in him .

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Disturbed Sensory Perception: Hallucinations related to Social Withdrawal

Nursing Care Plan for Hallucinations

Nursing Diagnosis : Disturbed Sensory Perception: Hallucinations related to Social Withdrawal

Goal : The client is able to control the hallucinations .

Outcomes :

• Patients can and want to shake hands .
• Patients want to mention names , would call out the name of the nurse and want to sit together .
• Patients can mention the cause of the client withdrew .
• Patients want to connect with other people .
• After a home visit to a client in touch with family gradually

Intervention :

1. Construct a trusting relationship .
2. Make a contract with the client .
3. Perform introductions .
4. A name calling .
5. Invite a conversation with a patient friendly .
6. Assess the client's knowledge about the behavior of withdrawn and the signs
7. and give the client a chance to express feelings cause the patient does not want to hang out / withdrawal.
8. Explain to the client about withdrawn behavior , and signs that may be the cause .
9. Give praise to the client's ability to express feelings .
10. Discuss about the advantages of touch .
11. Slowly and with the patient in the room activity through defined stages .
12. Give credit for the success that has been achieved .
13. Instruct the patient to independently evaluate the benefits of touch .
14. Discuss daily schedule to do the patient to fill his time .
15. Motivation patient in following activity room .
16. Give credit for participation in the activity room .
17. Perform kungjungan home , building a trusting relationship with the family .
18. Discuss with your family withdrawn behavior , and the causes of a family facing car .
19. Encourage family members to communicate .
20. Instruct patient's family members routinely visit patients at least once a week .

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Risk for Self or Other-directed Violence related to Hallucinations

Nursing Care Plan for Hallucinations

Nursing Diagnosis : Risk for Self or Other-directed Violence

Goal : Do not occur or other self -directed violence .

Outcomes:

• Patients can express their feelings in its current state verbally .
• Patients can mention the usual action when hallucinations , hallucinations and decide how to carry out an effective way for patients to use
• Patients can use the patient's family in a way to control hallucinations often interact with the family .

Intervention :

1. Construct a trusting relationship
2. Give the client the opportunity to express his feelings .
3. Listen to the client's expression of empathy
4. Hold a brief but frequent contacts gradually ( time adjusted to the client ) .
5. Observation of behavior : verbal and non- verbal hallucinations associated with .
6. Explain to the client signs to describe the behavior hallucinations hallucinations .
7. Identification with the client situation that raises and does not cause hallucinations , content , time , frequency .
8. Give the client the opportunity to express his feelings when natural hallucination .
9. Identification with the action taken when a client is experiencing hallucinations .
10. Discuss ways to decide hallucinations
11. Give the client a chance to reveal how to decide in accordance with the client's hallucinations .
12. Encourage clients to participate in group activity therapy
13. Instruct the client to notify the family when experiencing hallucinations .
14. Discuss with clients about the benefits of the drug to control hallucinations .
15. Help clients use the drug correctly .

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Risk for Fluid Volume Deficit related to Vomiting

Vomiting is defined as the discharge of the contents of the stomach up into the mouth by force. Vomiting can be an attempt removing toxins from the gastrointestinal tract such as diarrhea, lower gastrointestinal tract.

Vomiting can be caused by many things such as the following:

• Congenital abnormalities
• Infection of the digestive tract
• Feeding the wrong way
• Poisoned

Complications of vomiting are as follows :

• Dehydration or alkalosis, due to loss of body fluid / electrolyte
• Ketosis from not eating and drinking
• Acidosis caused a sustained ketosis can be a shock even to seizures
• Abdominal muscle tension, conjunctival hemorrhage, esophageal rupture, aspirations, caused by severe vomiting.

Persistent vomiting can lead to complications of dehydration, electrolyte disturbances, rips Mallory Wiess, aspiration of gastric fluid.


Nursing Diagnosis for Vomiting

Risk for Fluid Volume Deficit related to the feeling of nausea and vomiting

Goal: Maintain the balance of fluid volume.

Outcomes: The client does not nausea and vomiting.

Intervention:
1. Monitor vital signs.
Rationale: An early indicator of hypovolemia.

2. Monitor intake and output and urine concentration.
Rationale: Decreased urine output and concentration will improve the sensitivity / sediment as one impression of dehydration and require increased fluids.

3. Give fluid little by little but often.
Rationale: To minimize the loss of fluids.

4. The risk of infection associated with an inadequate immune, characterized by: body temperature above normal. Increased respiratory rate.

Source : http://nurseskomar.blogspot.com/2013/10/nursing-diagnosis-for-vomiting-risk-for.html

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Nursing Interventions for Encephalitis : Ineffective Tissue Perfusion

Nursing Diagnosis: Ineffective Tissue Perfusion related to increased intracranial pressure.

Goals:

• Patient's neurological status returned to the state before the illness.
• Increased patient awareness and sensory function.

Outcomes:

• Vital signs within normal limits.
• Reduced headache pain.
• Increased awareness.
• No signs or loss of increased intracranial pressure.

Intervention:

1. Total bedrest patients, with supine sleeping position without a pillow.
Rationale: Changes in inta-cranial pressure will be able to mislead the risk for brain herniation.

2. Monitor signs of neurological status with GCS.
Rational: It can reduce further brain damage.

3. Monitor vital signs such as blood pressure, pulse, temperature, respiration and caution in systolic hypertension.
Rational: In normal circumstances autoregulation maintains a state of altered systemic blood pressure fluctuation. Autoregulation failure will cause a cerebral vascular damage can be manifested by an increase followed by a decrease in systolic and diastolic pressure. While the increase in temperature can describe the course of infection.

4. Monitor intake and output
Rational: Hyperthermia can lead to increased IWL and increase the risk of dehydration, especially in patients who are not aware, and nausea were lower intake by mouth

5. Help the patient to limit vomiting, coughing. Instruct the patient to exhale when moving or turning in bed.
Rationale: Activity vomiting or coughing can increase intracranial and intra-abdominal pressure. Exhale when moving or changing position can protect themselves from the effects of Valsalva.

6. Give fluids per infusion with strict attention.
Rationale: Minimize the burden of vascular and fluctuations in intracranial pressure, fluid and fluid vetriksi can reduce cerebral edema.

7. Monitor blood gas analysis of oxygen delivery when needed.
Rational: The possibility of acidosis is accompanied by the release of oxygen at the cellular level may lead to the occurrence of cerebral ischemic.

8. Provide appropriate therapy such as physician advice: Steroids, Aminofel, Antibiotics
Rational Therapy given to decrease capillary permeability.
Lowering of cerebral edema
Lowered metabolic cells / consumption and seizures.

Source : http://nurseskomar.blogspot.com/2013/07/ineffective-tissue-perfusion-related-to.html

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Nursing Diagnosis : Imbalanced Nutrition related to Hyperemesis Gravidarum

Nursing Care Plan for Hyperemesis Gravidarum - Nursing Diagnosis : Imbalanced Nutrition: less than body requirements

Hyperemesis Gravidarum

Nausea and vomiting (emesis gravidarum) is a natural phenomenon and is often caught in the first trimester of pregnancy. Nausea usually occurs in the morning, but can arise at any time and at night. These symptoms occur approximately 6 weeks after the first day of the last menstrual period and lasts for approximately 10 weeks. Nausea and vomiting occur in 60-80% primi gravida and 40-60% multi gravida. One in every thousand pregnancies, these symptoms become more severe.

Nausea is largely attributable because of increased levels of estrogen and HCG (Human Chorionic Gonadrotropin) in serum. Physiological effect of the hormone increase is not clear, probably because the central nervous system or the gastric emptying of the stomach is reduced. In general, women can adapt to this situation, though symptoms of severe nausea and vomiting that can last up to 4 months. Daily work was interrupted, and the general condition became worse. This condition is called hyperemesis gravidarum. Complaints of symptoms and physiological changes determine the severity of the disease. (Prawirohardjo, 2002)

Hyperemesis gravidarum is defined as excessive vomiting or uncontrolled during pregnancy, which causes dehydration, electrolyte imbalance, or nutritional deficiencies, and weight loss. The incidence of this condition is approximately 3.5 per 1000 births. Although most cases of missing and disappeared over time, one out of every 1,000 pregnant women will undergo hospitalization. Hyperemesis gravidarum usually disappear on their own (self-limiting), but healing is slow and frequent relapses are common. The condition often occurs among primigravida women and tends to recur in subsequent pregnancies. (Lowdermilk, 2004).


Nursing Diagnosis for Hyperemesis Gravidarum : Imbalanced Nutrition: less than body requirements related to excessive frequency of nausea and vomiting.

Read More : http://nandahealth.blogspot.com/2013/09/imbalanced-nutrition-related-to.html

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Nursing Interventions for Apendicitis

Appendicitis is an inflammation of the appendix, a sac that no such additional functions located in the inferior and cecum. The most common cause of appendicitis is obstruction of the lumen by fecal eventually damage erode supply and mucosal blood flow, causing inflammation (Wilson & gold man, 1989).

Appendicitis is caused by blockage of the lumen of the appendix by fecalit, foreign objects, because there are previous inflammation. The obstruction causes mucus-producing mucosa, having the dam. However, the elasticity of the walls of the appendix has limitations that cause intra-luminal pressure. The increased pressure will inhibit the flow of lymph which will cause edema and ulceration of the mucosa, this occurs when the local acute appendicitis is characterized by the presence of pain.

Appendix unknown function, is part of the cecum. Inflammation of the appendix may occur by the presence of mucosal ulceration or obstruction of the lumen wall (usually by fecalit / hardened feces). Penymbatan spending mucus resulting in adhesions, and inhibition of bloodstream infections. Of hypoxia, resulting gangreng or rupture within 24-36 hours. If this process continues around the walls of organs appendix adhesions will occur that will cause an abscess (chronic). If the infection process is very fast will cause peritonitis.

Perforation signs include increased pain, muscle spasm right lower quadrant abdominal wall with a sign that generalized peritonitis or abscess localized, ileus, fever, malaise, leukocytosis increasingly clear. When perforation with generalized peritonitis or abscess formation has occurred since the increment clients outsmart come, the diagnosis can be established with certainty.

If peritonitis occurs, specific therapy is surgery performed to close the perforation origin. While the other acts as a support: Fowler position bed rest in the medium, the installation of NGT, fasting, correction fluids and electrolytes, giving tranquilizers, antibiotics with broad-spectrum antibiotics are continued in accordance with the culture, transfusion to treat anemia, and treatment of septic shock in the intensive , if any.


Preoperative Nursing Interventions for Apendicitis

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