Acute Pain related to Urinary Retention

Nursing Care Plan for Urinary Retention

Urinary retention is the inability to empty the bladder completely during the process of urine. (Brunner and Suddarth. (2010). Text Book Of Medical Surgical Nursing 12th Edition. Thing in 1370).

Causes of urinary retention, among others, diabetes, enlarged prostate gland, urethral abnormalities (tumor, infection, calculus), trauma, childbirth or neurological disorders (stroke, spinal cord injury, multiple sclerosis and Parkinson's). Some medications can cause urinary retention either by inhibiting bladder contractions or increased resistance of the bladder. (Karch, 2008)

Signs and Symptoms

• Beginning with a slow flow of urine.
• Then there are the longer polyuria became worse because of inefficient bladder emptying.
• Abdominal distention occurs due to dilatation of the bladder.
• Feels no pressure, pain and sometimes feel the urge to urinate.
• In severe retention could reach 2000 -3000 cc.

The diagnostic checks that can be performed on urine retention is as follows:

• Examination of the urine specimen.
• Decision: sterile, random, midstream.
• General retrieval: pH, BJ, Culture, Protein, Glucose, hemoglobin, ketones and Nitrite.
• Cystoscopy (examination of the bladder).
• IVP (Intravenous pyelogram) / X-ray with contrast material.

Nursing Diagnosis for Urinary Retention : Acute Pain related to distension of the bladder.

Goal: pain problems can be resolved.

Outcomes:

• Stating the pain is relieved / controlled.
• Shows relax, rest and increased activity appropriately.

Intervention:
1) Assess pain, note the location, intensity of pain.
R: Provides information to assist in determining interventions.

2) Plaster drainage hose on the thigh, and a catheter in the abdomen.
R: Preventing erosion withdrawal bladder and penile-scrotal meeting.

3) Maintain bed rest when indicated pain.
R: Bed rest may be necessary during the early phase of acute retention.

4) Provide comfort measures
R: Enhancing relaxation and coping mechanisms.

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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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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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