Anxiety Assessment and Nursing Diagnosis

Nursing Assessment for Anxiety

Assessment of the physiological function and behavior change through a symptom or coping mechanism, as a defense against anxiety.

Assess the predisposing factors
Predisposing factor is all the tensions in life can cause anxiety such as:

1. Traumatic events that can trigger a crisis of anxiety experienced by individuals, either developmental or situational crisis.
2. Emotional conflict experienced by individuals and are not well resolved. The conflict between the id and super ego, or between desire and reality can lead to anxiety in individuals.
3. Impaired self-concept will lead to the inability of individuals to think realistically that will cause anxiety.
4. Frustration will lead to a sense of powerlessness to make decisions that impact on the ego.
5. Physical disturbance will cause anxiety because it is a threat to physical integrity that may affect the individual's self concept.
6. Patterns of family coping mechanisms, or patterns of families dealing with setres will affect individuals in responding to conflicts experienced as patterns of individual coping mechanisms widely studied in the family.
7. History of anxiety disorders in families will affect the response of individuals in responding to conflict and overcome anxiety.
8. Medications that can trigger anxiety.

Assess the precipitation stressors

Precipitation stressor is any tension in life that can trigger the onset of anxiety. Precipitation anxiety stressors grouped into two parts:

1. The threat to physical integrity. Tensions that threaten the physical integrity include:

• Internal sources, including the failure of the physiological mechanisms of the immune system, regulation of body temperature, normal biological changes (eg pregnancy)
• External sources include exposure to viral and bacterial infections, environmental pollutants, malnutrition, inadequate shelter.

2. Threat to self-esteem, including internal and external sources.

• Internal source: difficulties in interpersonal touch at home and at work, adjustment to new roles. Various threats to the physical integrity of self-esteem may also be threatened.
• External sources: loss of a loved one, divorce, change of employment status, peer pressure, social culture.

Assess the behavior

Directly concerns can be expressed through physiological and psychological responses, and indirectly through floating coping mechanisms as a defense against anxiety.
1. Physiological response.
Activate the autonomic nervous system (sympathetic and parasympathetic)

2· Psychological Response
Anxiety can affect intrapersonal and personal aspects.

3· Cognitive Response.
Anxiety can affect your ability to think both the mind and isis thought, such is not able to pay attention, decreased concentration, forgetfulness, decline in the field of perception, puzzled.

4· Response affective.
Clients will be expressed in the form of confusion and suspicion over-emotional reaction to anxiety.


Nursing Diagnosis for Anxiety

1. Panic related to the rejection of the family because of confused and failed to make a decision.
2. Severe anxiety related to marital conflict.
3. Anxiety was related to financial pressures.
4. Ineffective individual coping related to the death of a sibling.
5. Ineffective individual coping related to the impact of sick children.
6. Fear associated with surgery plans.

Levels of Anxiety - Mild, Moderate and Severe

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Benefits of Breathing Exercises

Breathing exercises are a method of breathing in certain ways to enhance and improve the performance of breathing (respiration). Particularly in improving the performance of the lungs to absorb oxygen to be more optimal. An American study concluded that the breathing exercises for thirty seconds to two minutes, five times a day are performed routinely in 12 weeks will improve the performance of the lungs as much as 10 percent.

Why do we need to do these breathing exercises?

Well, here are some of the benefits of breathing exercises:

1. Stabilize blood pressure

Apparently, doing breathing exercises properly and regularly can stabilize blood pressure, which also means it can prevent hypertension (high blood pressure) or hypotension (low blood). Breathing exercises improve respiration, so oxygen is taken up by the lungs more and more, and circulatory organs to circulate blood with more oxygen content as well.

2. Remove the poison (toxin) in the body

Technically, these breathing exercises will push the system to work out an excretion of toxins in the body through urine, sweat, feces, etc..

3. Relieve stress

When you stress, try to draw a deep breath, then exhale vigorously in three seconds. Do this five times a day. This breathing exercise can make blood vessels flexible and not easy to be hard (tense), as well as the distribution of oxygen and food juices can become more fluent and well received by the brain. In effect, the mind and emotional tension will decrease. You also can sleep soundly.

4. Burn fat and beautify the body

You want to trim? Often try to do breathing exercises. When you do deep breathing exercises, try to hold my breath in the stomach (abdomen). In this exercise the abdominal muscles will tighten and the deposition of fat in the abdomen will also burned. The result, you will have a more beautiful body and slim.

How to train breathing?

It's easy, you just sit or lie down, then take a deep breath in through your nose as she counted until the count of three, hold for two seconds, then exhale for three seconds solid. Repeat for 30 seconds, five times a day.

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Levels of Anxiety - Mild, Moderate and Severe

Levels of Anxiety

1. Mild anxiety

Mild anxiety is a feeling that something is different and requires special attention. Increased sensory stimulation and helps the individual focus of attention for learning, doing, solving problems, feel, and protect themselves. Mild anxiety associated with the tension of everyday life events. At this level of perception of land to widen and individuals will be cautious and vigilant.

a. Physiological response

• Occasional shortness of breath
• Pulse and blood pressure increase
• Mild symptoms of the stomach
• Wrinkled face and lips tremble
• Mild muscle strain
• Relaxed or less anxious

b. Cognitive response

• Able to accept that complex excitatory
• Concentrate on the problem
• Solve problems effectively
• Little sense of failure
• Be alert and pay attention to many things
• Look calm and confident
• Optimal learning rate

c. Behavioral and Emotional Response

• Unable to sit still
• Fine tremor of the hands
• Voice sometimes rising
• A little impatient
• Activity tends to be alone

2. Moderate anxiety

Moderate anxiety is a disturbing feeling that something really different, people become nervous or agitated. For example, a woman visiting her mother for the first time in several months and feel that there is something very different. Mom said that the weight down a lot without trying to reduce it. At this level of land decreases the perception of the environment, individuals are more focused on the important thing was to the exclusion of anything else.

a. Physiological responses

• Intermediate muscle tension
• Vital signs improved
• Pupillary dilation, began to sweat
• Often paced, slapped hands
• Sound change: a shaky voice, high voice
• Increased alertness and tension
• Frequent urination, headaches, sleep pattern changes, back pain

b. Cognitive response

• Field perception of declining
• No attention is selectively
• The focus of the stimulus increases
• Decreased attention span
• Decreased problem-solving
• Learning takes place by focusing

c. Behavioral and emotional responses

• uncomfortable
• sensitive
• Confidence shaken
• Unconsciousness
• excited

3. Severe anxiety

Severe anxiety is experienced when an individual believes that there is something different and there is a threat: it shows the response of fear and distress. When individuals reach the highest level of anxiety, severe panic, all rational thinking stops and the individual is experiencing the fight, flight, the need to go as soon as possible, remain in place and fight, or be frozen or can not do anything.

a. Physiological responses

• Severe muscle tension
• hyperventilation
• Poor eye contact
• Transpiration increased
• Fast talking, high-tone
• Aimless and haphazard actions
• jaw tightened
• The need for increased space
• Pacing, yelling
• Wringing hands, shaking

b. Cognitive response

• Limited field of perception
• Fragmented thought processes
• It's hard to think
• Poor problem-solving
• Unable to consider the information
• Just watch the threat
• Preokupasi with a mind of its own
• Egocentric

c. Behavioral and emotional responses

• very anxious
• agitation
• fear
• confused
• Feeling inadequate
• withdraw
• denial
• want to be free

Anxiety Assessment and Nursing Diagnosis

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Nursing Management and Diagnosis for CHF

Definition :

A state of pathophysiological abnormalities in cardiac function resulting in heart failure to pump blood to meet the metabolic needs of tissues and or ability only if accompanied by elevation of left ventricular filling pressure.

Etiology :
A. mechanical abnormalities

• Increased burden of the central (aortic stenosis), peripheral (systemic hypertension)
• Increase in volume load (initial load increase)
• Obstruction of the ventricular filling (stenosis mitralis / trikuspidalis)
• Pericardial tamponade
• Restriction endocardium / myocardium
• Ventricular aneurysm.

B. Abnormalities of the myocardium
1. Primary

• Cardiomyopathy
• Myocarditis
• The metabolic abnormalities
• Toxicity (alcohol, cobalt)

2. Dis-dynamic abnormalities, secondary

• K (-) O2
• The metabolic abnormalities
• Inflammation
• Systemic Diseases
• COPD

C. Changes in heart rhythm

• Cardiac arrest
• Fibrillation
• Tachycardia / bradycardia
• Electric Asinkroni

Signs and symptoms of CHF

1. Left heart failure

• Fatigue
• Weak
• Cyanosis
• Dyspnea
• Cough
• Orthopnea
• Anorexia
• Tachypnea
• The first heart sound decreases
• Wet crackles pleural effusion

2. Right heart failure

• Weight loss
• Ankle edema
• Abdominal distention
• Pain subkostal
• Pulsation neck region
• Jaundice
• Tired
• Edema, ascites
• Increased jugular venous pressure

Complication

• Cardiac asthma? due to bronchospasm occurs at night or in the activity
• Non-productive cough due to lung congestion
• Haemoptysis
• Dysphagia due to distension of the pulmonary venous atrium or
• Containment of systemic veins - JVP increased
• Hepatomegaly
• Peripheral edema
• Ascites and anasarka
• Increase in body weight due to water retention and sodium
• Peripheral vasoconstriction? release of body heat (-)
• Abnormalities of liver function, prothrombin time emanjangan light.

Nursing Management of CHF

Goal :
- Reducing the workload of the heart
- A third of selective manipulation of the main determinants of myocardial function, namely:

• the initial load
• the load end
• contractility

- Achieve the desired clinical response

Guidelines:
1. Limitation of physical activity

• Avoid strenuous work
• Stop the heavy exercise

2. sodium restriction
3. digitalis glycosides
4. diuretics

• Diuretics
• Potassium-sparing diuretics

5. vasodilator
6. inotropic agents
7. specific actions:

• Consideration tranpalntasi
• Assisted circulation:

Nursing Diagnosis for CHF

1. Decreased cardiac output related to mechanical factors (preload, afterload, contractility)
2. Impaired gas exchange related to alveolar capillary membrane due to increased pulmonary capillary pressure
3. Changes in nutritional status: less than body requirement related to the absorption of nutrients secondary to decreased cardiac output.
4. Activity intolerance related to decreased cardiac output.

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Hyperglycemic Hyperosmolar Nonketotic Symptoms and Pathophysiology

Hyperglycemic hyperosmolar nonketotic - Signs and Symptoms

Signs and symptoms common in hyperglycemic hyperosmolar nonketotic client is thirsty, warm and dry skin, nausea and vomiting, decreased appetite (weight loss), abdominal pain, dizziness, blurred vision, a lot of urine, tiredness, polydipsia, polyuria, impairment of consciousness.

The symptoms include:
1. Somewhat sleepy stupor incident, often comma.
2. Polyuria for 1 -3 days before clinical symptoms arise.
3. No hyperventilation and no bad breath.
4. Very excessive volume depletion (dehydration, hypovolemia).
5. Serum glucose reaches 600 mg / dl to 2400 mg / dl.
6. Sometimes there are gastrointestinal symptoms.
7. Hypernatremia.
8. Failure that resulted in the thirst mechanism is inadequate digestion of water.
9. High serum osmolarity with minimal CNS symptoms (disorientation, convulsions local).
10. Impaired renal function.
11. HCO3 levels less than 10 mEq / L.
12. Normal CO2 levels.
13. Anion gap is less than 7 mEq / L.
14. Serum potassium is usually normal.
15. No ketonemia.
16. Mild acidosis.

Pathophysiology of Hyperglycemic Hyperosmolar Nonketotic

Hyperglycemic hyperosmolar nonketotic syndrome portrait of insulin deficiency, and excessive hormone glucagon. Decrease insulin resistance causes glucose movement into cells, resulting in the accumulation of glucose in plasma. Increase in the hormone glucagon which causes glycogenolisis can increase plasma glucose levels. Increased glucose levels lead to hyperosmolar. Serum hyperosmolar conditions would attract intracellular fluid into the intra vascular, which can lower the intracellular fluid volume. If the client does not feel the sensation of thirst will cause dehydration.

High levels of serum glucose are excreted in the kidneys, causing glycosuria which can lead to excessive osmotic diuresis (polyuria). The impact of polyuria would cause excessive fluid loss, and followed the loss of potassium, sodium and phosphate.
Due to lack of insulin the glucose can not be converted into glycogen to increase blood sugar levels and hyperglycemia occurs. The kidneys can not resist hyperglycemia, because the threshold for blood sugar was 180 mg% in case of hyperglycemia so that the kidneys can not filter out and absorb the amount of glucose in the blood. With respect to the nature of the sugar which absorbs all the excess water removed with the urine is called glucosuria. Simultaneously the state of glucosuria then some water is lost in the urine is called polyuria. Polyuria resulting in intra cellular dehydration, this will stimulate the thirst center so that patients will feel constantly hungry, so the patient will continue to drink the so-called polidipsi. Decreased renal perfusion resulting in increased secretion of the hormone over again and hyperglycemic hyperosmolar arise.

The lack of insulin production will cause a decrease in glucose transport into the cells so the cells are starved of food and stores carbohydrates, fats and proteins to be depleted. Because it is used to burn the body, then the client will feel hungry eat, causing many so-called poliphagia.

Failure to restore the body's homeostasis situation will lead to hyperglycemia, hyperosmolar, excessive osmotic diuresis and dehydration. Central nervous system dysfunction due to transport oxygen to the brain disorder and tends to be a comma.
Hemoconcentration increases the blood viscosity which may lead to the formation of blood clots, thromboembolism, cerebral infarction, heart.

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Nursing Intervention and Implementation of Low Back Pain

Lower back pain is one of the leading reasons people in the United States visit their doctors. It will inhibit the lives of millions of Americans this year. In fact, an average four out of five adults will experience low back pain at some point in their lives. So the question, "What is causing my lower back pain?" is not uncommon.

Three categories of lower back pain

Your lower back pain will fall into one of three categories, which your doctor bases on your description of the pain.

1. Axial lower back pain - mechanical or simple back pain

2. Radicular lower back pain - sciatica

3. Lower back pain with referred pain



Nursing Intervention and Implementation of Low Back Pain

1. Relieve pain
To reduce pain nurses can encourage patients to bed rest and changing sleeping position is determined, to improve lumbar flexion. Patients are taught to control and adjust the pain, which is done through the respiratory diaphragm and relaxation can help reduce muscle tension that contributes to lower back pain. Distract patients from pain with other activities such as reading books, watching TV and the imagination (imagine the fun things by focusing on it).
Gently massage the soft tissue is very useful for reducing muscle spasms, improve circulation and reduce the damming and reduce pain. When given a drug nurse should assess the patient's response to each drug.

2. Improve physical mobility
Physical mobility is monitored through continuous assessment. Nurses assess how patients move and stand. Once the back pain is reduced, self-care activities may be done with minimal strain on the injured structure. Change of position should be done slowly and assisted if necessary. The twist and sway should be avoided. Patients are encouraged to switch the activity of lying, sitting and walking around for a long time. Nurses should encourage patients to comply with appropriate training program established, training is just not effective.

3. Improve proper body mechanics
Patients must be taught how to sit, stand, lie down and lift items correctly.

4. Health education
Patients must be taught how to sit, stand, lie down and lifting objects properly

5. Improve the performance of the role
Responsibilities associated with the role may have changed since the onset of lower back pain. Once the pain healed, patients can return to his role of responsibility again. However, if the activity is impacting on the bottom of my back pain again, it may be difficult to return to the original liability without bearing the risk of chronic low back pain with disability and depression caused.

6. Changing nutrition and weight loss
Weight loss through the adjustment of feeding can prevent recurrence of back pain, by means of the rational nutrition plan that includes changes in eating habits to maintain a desirable weight.

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NIC NOC - Ineffective airway clearance related to Pleural effusion

Pleural effusion is an abnormal accumulation of fluids in the pleural space Between the parietal and visceral pleura of the Lungs. Breathlessness, chest pain and non-productive cough are the most common symptoms associated with pleural effusion.

Nursing Diagnosis and Interventions for Pleural effusion

Nursing Diagnosis: Ineffective airway clearance related to weakness and poor cough effort.

NOC:

• Demonstrate effective airway clearance and respiratory status evidenced by, gas exchange and ventilation are not dangerous:
- Having a patent airway
- Removing secretions effectively.
- Having a rhythm and respiratory frequency in the normal range.
- Having a pulmonary function within normal limits.

• Demonstrate adequate gas exchange, characterized by:
- Easy to breathe
- There is no anxiety, cyanosis and dyspnea.
- O2 saturation within normal limits
- Chest X-ray within the expected range.

NIC:
• Assess and document
- The effectiveness of the administration of oxygen and other treatments.
- The effectiveness of treatment.
- Trends in arterial blood gases.
• Auscultation of the anterior and posterior chest to find a decrease or absence of ventilation and the presence of noise barriers.
• Sucking airway
- Determine the need for oral suction / tracheal.
- Monitor the status of oxygen and hemodynamic status and cardiac rhythm before, during and after exploitation.
• Maintain adequacy of hydration to decrease viscosity of secretions.
• Explain the use of ancillary equipment properly, such as oxygen, suction equipment lenders.
• Inform the patient and family that smoking is an activity that is prohibited in the treatment room.
• Instruct the patient about the coughing and deep breathing techniques to facilitate the discharge of secretion.
• Negotiate with the respiratory therapist as needed.
• Give oxygen that has been humidified.
• Tell your doctor about the results of an abnormal blood gas analysis.
• Assist in the delivery of aerosol. Nebulizer and another lung treatment in accordance with institutional policies and protocols.
• Encourage physical activity to improve the movement of secretions.
• If the patient is unable to ambulate, the patient lies sleeping position changed every 2 hours.
• Inform the patient before beginning the procedure to reduce anxiety and increase self-control.

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Torch Infections In Pregnancy : Toxoplasma, Rubella, Cytomegalovirus, Herpes simplex

TORCH is a term used to describe the combination of four types of infectious diseases is Toxoplasma, Rubella, Cytomegalovirus, and Herpes. The fourth type of defect of this infection, is equally harmful to the fetus if the infection suffered by pregnant women.

Now, for the diagnosis of infectious diseases has grown among other toward the immunological examination.

The principle of this examination is the detection of specific antibodies against germs that cause infections such as the body's response to foreign bodies (germs). Antibodies are the worst may be immunoglobulin M (IgM) and immunoglobulin G (IgG).

Toxoplasma

Toxoplasma infection is caused by a parasite called Toxoplasma gondii.
In general, Toxoplasma infections occur without specific symptoms. Only approximately 10-20% of cases of infection.

Toxoplasma is accompanied by mild symptoms, such as influenza symptoms, can result in fatigue, malaise, fever, and generally do not cause problems.

Toxoplasma infection occurs when harmful when pregnant women or in people with compromised immune systems (eg people with AIDS, organ transplantation patients who received the drug suppressing the immune response).

If a pregnant woman infected with Toxoplasma is a result that can happen is a spontaneous abortion or miscarriage (4%), birth and death (3%) or infants suffering from congenital toxoplasmosis. On congenital toxoplasmosis, symptoms can appear as an adult, such as eye and ear disorders, mental retardation, seizures and encephalitis.

Toxoplasmosis diagnosis is clinically difficult to determine because the symptoms are not specific or even no symptoms (sub clinical). Therefore, laboratory tests are absolutely necessary to get a proper diagnosis. Examinations are commonly performed anti-Toxoplasma IgG, IgM and IgA, and IgG avidity anti-Toxoplasma.

Examination needs to be done on people suspected of being infected with Toxoplasma, the mothers before or during pregnancy (when a negative result should be repeated once a month, especially in the first trimester, then each trimester), and newborns of mothers infected with Toxoplasma.

RUBELLA

Rubella infection characterized by acute fever, rash and enlarged lymph nodes. The infection is caused by Rubella virus, can attack children and young adults.

Rubella infection, harmful if happens to young pregnant women, because it may cause abnormalities in babies. If infection occurs in the first month of pregnancy, the risk of abnormalities was 50%, whereas if infection occurs first trimester the risk is 25% (according to the American College of Obstatrician and Gynecologists, 1981).

Signs and symptoms of rubella infection varies for each individual, even in some patients go unrecognized, especially if the rash does not appear red. Hence, proper diagnosis of rubella infection need to be enforced with the help of laboratory tests.

Laboratory examinations performed included examination of Anti-Rubella IgG and IgM.

Examination of Anti-rubella IgG can be used to detect the presence of immunity during pregnancy. If they are not immune, it is recommended to be vaccinated.

Examination of Anti-rubella IgG and IgM is particularly useful for the diagnosis of acute infection in pregnancy <18 weeks and the risk of congenital rubella infection.

Cytomegalovirus (CMV)

CMV infection is caused by a virus Cytomegalo, and these virus groups including the Herpes virus family. As with other herpes family, CMV virus can stay latent in the body and CMV infection is one cause that is harmful to the fetus if the infection is harmful to the fetus if infection occurs when the mother was pregnant.

If pregnant women are infected. the fetus at risk of contracting the disorder such that an enlarged liver, jaundice, brain calcifications, deafness, mental retardation, and others.

Laboratory tests are very useful to know the acute infection or recurrent infections, in which acute infection have a higher risk. Laboratory tests performed included anti-CMV IgG and IgM, and IgG avidity anti-CMV.

HERPES SIMPLEX TYPE II

Herpes infection of the genitals (sex) is caused by herpes simplex virus type II (HSV II). The virus can be in the form of latent, creeping through the sensory nerve fibers and ganglion settles in the autonomic nervous system.

Babies born to mothers infected with HSV II usually showed blisters on the porters, but this does not always appear so it may not be known. HSV II infection in newborns can be fatal (In more than 50 cases)

Laboratory tests, the Anti-HSV II IgG and IgM is essential for early detection of the possibility of infection by HSV II and mencaegah further danger to the infant when infection occurs during pregnancy.

TORCH infections that occur in pregnant women DAPT harm the fetus. TORCH infection, clinical symptoms are indistinguishable from Searing other diseases because the symptoms are not specific. Although there are giving these symptoms do not appear so difficult for doctors to perform diagnosis. Therefore, the laboratory is needed to help find out TORCH infection so the doctor can provide appropriate treatment or therapy.

TORCH panel
● Anti-Toxoplasma IgG and IgM
● Anti-Rubella IgG and IgM
● Anti-CMV IgG and IgM
● Anti-HSV II IgG and IgM

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Breastfeeding Benefits for Baby

Breastfeeding Benefits for Baby

Breastfeeding for the baby would have been very beneficial. There are so many benefits of breast milk that are needed by the infant. The advantages and benefits of breastfeeding can be viewed from several aspects including the nutritional aspects. When viewed from the aspect of nutrition, there are four benefits of colostrum in breast milk is important to know the mothers and very useful for the baby.

First, colostrum contains important antibodies, particularly IgA to protect infants from infectious diseases, especially diarrhea.

Second, the amount of colostrum produced varies depending on the baby sucking on the first days of birth. Although a little but enough to meet the nutritional needs of infants. Therefore, colostrum should be fed to infants.

Third, Colostrum contains protein, vitamin A and high carbohydrate and low fat, so that according to the nutritional needs of infants in the first days of birth.

Fourth, help remove the meconium is baby's first feces, greenish-black.

In addition, the mothers also need to know three things on the composition of breast milk.

First, breast milk is easily digested, because in addition to containing the appropriate nutrients, it also contains enzymes to digest the nutrients contained in the milk.

Secondly, breast milk contains nutrients that are useful for high-quality growth and development of the intelligence of babies / children.

Third, in addition to containing high protein, milk has a ratio between Whei and Casein that is suitable for babies. Whei ratio with Casein is one of the benefits of breast milk compared with cow's milk, breast milk contains more whey is 65:35. This causes the protein composition of breast milk is more easily absorbed. Whereas in cow's milk has a ratio of Whey: Casein is 20: 80, so it is not easily absorbed.

Not only that, the mother is also important to know the composition of Taurine, DHA and AA in breast milk.

First, Taurine, an amino acid is a kind of second most abundant in breast milk that serves as a neuro-transmitter, and plays an important role for the maturation of brain cells. Experiments in animals indicate that taurine deficiency will result in a disruption in the retina of the eye.

Second, Decosahexanoic Acid (DHA) and Arachidonic Acid (AA) is an unsaturated fatty acid chain length (polyunsaturated fatty acids) are required for the formation of brain cells is optimal. The amount of DHA and AA in breast milk is sufficient to ensure growth and intelligence of children. Besides DHA and AA in the body can be formed or synthesized from its constituent substance (precursor) respectively of Omega 3 (linolenic acid) and Omega 6 or linoleic acid. (Yz)

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Nursing Theory of Self Care Deficit - By Dorothea E. Orem

Theory of Self Care Deficit. This theory is at the core of the theory of Orem. Lack of self-care is the relationship between self-care agency and therapeutic self-care self-care agency in which the demand is not able to meet the needs of self-care.

Orem identified 5 methods to provide nursing assistance:

1. Providing direct services in the form of nursing actions
2. Provide direction and facilitate the client's ability to meet needs independently.
3. Provide physical and psychological boost to be able to develop a potential client, so it can perform maintenance on their own.
4. Provide and maintain an environment that supports personal development clients to increase independence in care.
5. Teach clients about the procedures and other aspects of the action that the client can perform self-care independently.

Nurses can help individuals by using these methods in providing assistance with personal care. To be able to provide appropriate assistance, the nurse must assess the client's condition to determine the appropriate method.

Orem defines five areas of nursing practice activities:

1. Fostering and maintaining good nurse-client relationship of individuals, families or groups up to the clients home.
2. Determine the condition of clients who require nursing assistance.
3. Responds to requests, wishes and needs of clients and contacts will help caregivers.
4. Establish, provide and regulate aid directly to the client.
5. Coordinate and integrate nursing care with daily activities of clients, other health care, provision of social services and education needed or being received.

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Nursing Diagnosis and Interventions for Fever

Nursing Diagnosis for Fever and Nursing Interventions for Fever

1. Nursing Diagnosis: Hypertermia related to the infection process

Goal: The temperature within normal limits

Expected outcomes are:

1. Free from cold
2. Stable body temperature 36-37 C

Intervention:

1. Monitor the temperature of the client (the degree and pattern) note the chills / diaphoresis
2. Monitor the temperature of the environment, limit / add the bed linen as indicated
3. Give a warm compress to avoid the use of alcohol
4. Give the drink as needed
5. Collaboration for the provision of antipyretics

2. Nursing Diagnosis: Risk for Injury related to repetitive strain

Goal: free from injury

Expected outcomes are:

1. shows the homeostatic
2. no mucosal bleeding and free from other complications

Intervention:

1. Review the signs of complications
2. Assess the status of cardiopulmonary
3. Collaboration for laboratory monitoring: monitor routine blood
4. Collaboration for the administration of antibiotics

3. Nursing Diagnosis: Fluid Volume Deficit related to the intake of less

Goal: Adequate fluid volume

Expected outcomes are:

1. vital signs within normal limits
2. strong peripheral pulses palpable
3. adequate urine output
4. there are no signs of dehydration

Intervention:

1. Measure / record the urine output and specific gravity. Record the input and output cumulative imbalance
2. Monitor blood pressure and heart rate
3. Palpation of peripheral pulses
4. Review of dry mucous membranes, poor skin tugor and refined taste
5. Collaboration for the administration of IV fluids as indicated
6. Monitor laboratory values

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5 Types of Fever You Need to Know

Fever is the body temperature rising abnormally. Fever is generally defined in body temperature above 37.2 º C.

Fever can be an early sign of infection, as the body attempts to eliminate the bacteria/virus by rising the body's temperature. This is common among children and postoperative patients. And as a nurse, we will need to devise a nursing care plan that will help patients' temperature to return to normal.

Type of fever that may be encountered include:

1. Septic Fever
Temperature gradually rose to the level that high once at night and fall back to the level above normal in the morning. Complaints are often accompanied by chills and sweating.

2. Remittances Fever
Body temperature can go down every day but never reached normal body temperature. Causes may be recorded temperatures can reach two degrees and no temperature differences were noted for septic fever.

3. Intermittent Fever
Body temperature dropped to the level of normal for several hours in a day. When the fever as it occurs within two days once called tersiana and if there are two free days of fever between the two bouts of fever called kuartana.

4. Continuous Fever
Temperature variations throughout the day did not differ by more than one degree. At the level of persistent high fever once called hyperpyrexia.

5. Cyclic Fever
An increase in body temperature for several days, followed by a period free of fever for several days followed by a rise in temperature as before.

A type of fever is sometimes associated with a particular disease such as type of intermittent fever for malaria. A patient with symptoms of fever may be connected immediately with an obvious cause such as abscesses, pneumonia, urinary tract infections, malaria, but sometimes simply can not be connected immediately with an obvious cause. In practice 90% of the patients with fever who had just experienced, is primarily a self-limiting illness such as influenza or other similar viral diseases. But this does not mean we do not have to remain vigilant against bacterial infection.

Nursing Diagnosis and Interventions for Fever

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Nursing Care Plan for Corneal Ulcer

Nursing Care Plan for Corneal Ulcer

Nursing Diagnosis for Corneal Ulcer - Nursing Interventions for Corneal Ulcer

The cornea is the film at the front of the eye. An ulcer is an open sore on the surface caused by a break. It fails to heal and so begins to form a crater like wound. So a corneal ulceration is when the front film of the eye is damaged and doesn't heal. The vision is badly affected in that eye.

Corneal ulcer is described as an open sore that may be observed or appears around the cornea from the eyes, or the movie in entrance with the eyes. This occurs when the eye's entrance movie is damaged and doesn't heal and it can significantly impact the eyesight. Each animals and individuals can endure from this situation.

Nursing Diagnosis for Corneal Ulcer:

a. Anxiety related to damage to sensory and lack of understanding of post-operative care, drug delivery

Nursing interventions:
- Assess the degree and duration of visual impairment
- Orient the patient to the new environment
- Describe the routine perioperative
- Encourage to perform daily living habits when able
- Encourage the participation of the family or the people who matter in patient care.

b. Risk for Injury related to damage vision

Nursing interventions:
- Help the patient when able to do until a stable postoperative ambulation
- Orient the patient in the room
- Discuss the need for the use of metal shields or goggles when necessary
- Do not put pressure on the affected eye trauma
- Use proper procedures when providing eye drugs

c. Acute Pain related to trauma, increased IOP, surgical intervention or administration of inflammatory eye drops dilator

Nursing interventions:
- Give the medication to control pain and the IOP as prescribed
- Give cold compress on demand for blunt trauma
- Reduce lighting levels
- Encourage use of sunglasses in strong light

d. Risk for self-care deficit related to damage vision

Nursing interventions:
- Give instructions to the patient or the people closest to the signs and symptoms, complications should be immediately reported to the doctor
- Provide verbal and written instructions to patients and the right means of technique in delivering drugs
- Evaluate the need for assistance after discharge
- Teach patients and families of sight guidance techniques

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Nursing Diagnosis for Diabetes Mellitus

Diabetes Mellitus (DM)

Diabetes Mellitus (DM) is a disease caused by defective carbohydrate metabolism and characterized by abnormally large amounts of sugar in the blood and urine. Diabetes mellitus is usually classified into two types. Type I or "insulin-dependent" diabetes mellitus (IDDM), formerly called juvenile-onset diabetes, which occurs in children and young adults has been implicated as one of the autoimmune diseases. Type II or "non-insulin-dependent" diabetes mellitus (NIDDM), formerly called adult-onset diabetes is found in persons over 40 years old and progresses slowly.

Diabetes Mellitus that is characterized by hyperglycemia or dangerously high blood sugar levels can be caused either by not enough secretion of insulin which is generally caused by defects in the pancreas or the development of insulin resistance by cells that lead to the lack of capacity to properly utilize insulin.

Nursing diagnosis is the individual response to actual and potential problems, which meant the actual problem is a problem that was found at the time of assessment, while a potential problem is likely to arise later.

Nursing Diagnosis for Diabetes Mellitus

Nursing Diagnosis that may appear on the client with Diabetes Mellitus by Carpenitto, Doengoes, Sorensen and Brunner and Suddart include:

1) Imbalanced Nutrition Less Than Body Requirements related to reduction of carbohydrate metabolism due to insulin deficiency, inadequate intake due to nausea and vomiting.

2) Fluid Volume Deficit related to osmotic diuresis from hyperglycemia, polyuria, decreased fluid intake.

3) Impaired Skin Integrity related to decreased sensory sensation, impaired circulation, decreased activity / mobilization, lack of knowledge of skin care.

4) Activity Intolerance related to weakness due to decreased energy production.

5) High risk of injury associated with decreased sensation sensory (visual), weakness, and hypoglycemia.

6) Anxiety related to a lack of knowledge (diabetes management), the ability to remember the less, diagnosis or treatment of a new way, cognitive limitations.

7) Risk for ineffective management of therapeutic rules at home due to a lack of knowledge about the condition of the therapeutic management, inadequate support systems.

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Nursing Care Plan for Erythrodermic Psoriasis

Nursing Diagnosis for Erythrodermic Psoriasis
Nursing Interventions for Erythrodermic Psoriasis

Erythrodermic psoriasis is a medical disorder that affects the skin severely and causes it to be red, itch, swell, bleed, and form scale or flake etc. This medical condition is a rare but very serious reoccurring skin disorder caused by an inflammation of the skin cells due to abnormalities in the immune system.

Erythrodermic Psoriasis. This kind of psoriasis is far more harmful than all the other kinds of this auto immune disease. It may appear together with pustular psoriasis. In this kind of psoriasis, your skin displays a fiery red color on the lesions, that can wide spread all your body.

Often times, the Erythrodermic Psoriasis requires hospitalization. So, if you have skin lesions on many parts of your body, you may consult a good dermatologist on your location.

There is pain, itching and swelling of the body in erythrodermic psoriasis which is a grave type of disorder, caused by inflammation of skin cells which hampers the normal functioning of the body. There is a rise in the body temperature and the body tends to lose body fluids and proteins.

This condition is commonly seen in people who are already suffering from psoriasis and is a serious disorder. Without a past history of psoriasis, this condition hardly occurs.

Signs and Symptoms of Erythrodermic Psoriasis : 1) the skin becomes pale and red, 2) The body will be hot from a rise in temperature and loss in body fluid and proteins, 3) The patches on the skin will begin to fall off (like it's exfoliating or shedding off), 4) There will be a feelings of pain, 5) The skin will begin to itch, 6) The Body will have shivering fever, 7) Most body parts will begin to swell (e.g. ankles).

Erythrodermic psoriasis if left unattended to could cause life threatening illness like hypertension, failure of the heart, infections, body dehydration and a lot more.

If erythrodermic psoriasis is unattended then it may lead to certain life threatening conditions like infections, heart failure, hypertension, body dehydration, etc.

Nursing Diagnosis and Nursing Interventions for Erythrodermic Psoriasis

1. Impaired skin integrity related to the lesion and inflammatory response.

Expected outcomes are:
- Demonstrate an increase in skin integrity
- Avoid injury to the skin

Nursing Interventions:
a. examine the skin in general circumstances
b. instruct the patient to not pinch or scratch the skin area
c. keep the skin moist
d. reduce the formation of scales with the provision of bath oil
e. patient's motivation for consuming nutrients: high in calories and high in protein.

2. Risk for Infection related to hypoproteinaemia

Purpose: no infection
Expected outcomes are:
- There are no signs of infection (rubor, calor, dolor, fungsiolaesa)
- No new injuries occur

Nursing Intervention :
a. monitor vital signs
b. examined for signs of infection
c. patient's motivation to improve nutrition: high in calories and high in protein.
d. keep the wound clean
e. collaboration antibiotics

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Impaired Verbal Communication related to Delusions

Nursing Diagnosis Impaired Verbal Communication related to Delusions

General Objectives:

• No damage verbal communication

Specific objectives:

1. Clients can build trusting relationships with caregivers
Nursing Interventions:

• Construct a trusting relationship: therapeutic greetings, introduce yourself, explain the purpose of interaction, create a peaceful environment, create a contract that clearly the topic, time, forging).
• Do not argue and support the client's delusions: tell the nurse receives a client confidence "I accept your beliefs" with the expression of receiving, say nurses do not support, accompanied by expressions of doubt and empathy, the client does not discuss the content of delusions.
• Make sure the client is in a safe and secure: tell the nurse will accompany the client and the client is in a safe place, use the openness and honesty do not leave the client alone.
• Observation of whether delusions interfere with daily activities and self-care.

2. Clients can identify the capabilities of the
Nursing Interventions:

• Give praise to the appearance and the ability of clients to be realistic.
• Discuss with the client's capabilities in the past and present realistic.
• Ask me what I used to do then recommend to do it now (to associate with the day to day activity and self-care).
• If the client is always talking about delusions, delusions do not listen to the needs there. Show the client that the client is very important.

3. Clients can identify unmet need
Nursing Interventions:

• Observation of daily needs of clients.
• Discuss the unmet needs of clients both at home and during hospital (pain, anxiety, anger)
• Connect the unmet needs and the emergence of delusions.
• Increase activities that can meet the needs of clients and takes time and effort (for the schedule if possible).
• Set the situation so that the client does not have time to use a delusion.

4. Clients can be in touch with reality
Nursing Interventions:

• Talking with clients in the context of reality (self, other people, places and times).
• Include the client in a therapy group activity: reality orientation.
• Give praise to the positive activities undertaken each client

5. Clients can use the drug properly
Nursing Interventions:

• Discuss with the client regarding the drug name, dose, frequency, effects and side effects of medication
• Help clients use the drug with the principle of 5 correct (patient name, drug, dose, method and time).
• Encourage clients to discuss the effects and side effects of perceived drug
• Give reinforcement when clients take the correct medication.

6. Clients can support from family
Nursing Interventions:

• Discuss with the family through family meetings about: delusional symptoms, how to care for clients, family and follow-up drug.
• Give reinforcement for family involvement.

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Nursing Diagnosis Interventions for Risk for Violence - Schizophrenia

Nursing Interventions for Risk for Violence - Schizophrenia

Schizophrenia is a kind of mental disorder that makes it difficult to differentiate between the real and unreal experiences, to think rationally, to have normal emotional management and to be sociable to others.

Types of schizophrenia:

- Paranoid schizophrenia
- Catatonic schizophrenia
- Disorganized schizophrenias

People who have this brain disorder have an altered reality perception. They may able to hear and see things that do not exist, speak in weird or unclear ways, and believe that someone is trying to hurt them, or even feel like someone is constantly watching them. However, this condition can be manageably treated and cured.


Nursing Diagnosis Risk for Violence: Self-Directed or Other-Directed

related to:

1. Lack of trust: distrust of others
2. Panic
3. Stimulation of catatonic
4. The reaction of anger
5. Instructions of hallucinatory
6. Mind delusions
7. Walking back and forth
8. Jaw stiffness; clenched his fists, rigid posture
9. Aggressive action: direct purpose of destroying objects that are in the surrounding environment
10. Active self-destructive behavior; aggressive suicide
11. The words of a threatening, hostile; act of bragging to the psychological torment of others
12. Increased motor activity, footsteps, excitement, irritability, restlessness.
13. Perceive the environment as a threat.
14. Receive a "messenger" through hearing or sight as a threat.

Long-term goals:
Patients will not endanger themselves and others over at the Hospital.

Short term goals:
Within 2 weeks the patient can recognize the signs of increased anxiety and restlessness, and report to the nurse agaar given intervention as needed.


Nursing Interventions for Schizophrenia : Risk for Violence

(A) Keep the patient's environment at low stimulus levels (low lighting, a few, simple decor, low noise level).
Rational:
Anxiety levels will increase in an environment full of stimulus.Individu-existing individuals may be perceived as a threat because of suspicious, and eventually make the patient agitation.

(B) Observe closely the behavior of the patient (every 15 minutes). Do this as a routine activity for the patient to avoid any suspicion in the patient.
Rational:
Close observation is important, because then appropriate interventions can be provided immediately and to always ensure that patients are safe.

(C) Remove all objects that can harm the environment around the patient
Rational:
If the patient is in a state of anxiety, confusion, patients will not use these objects to endanger yourself or others.

(D) Try to channel your self-destructive behavior to the physical kegiatn to reduce patient anxiety (eg, hitting sandbags).
Rational:
Physical exercise is a safe way to menghilaangkan efektf latent tensions.

(E) Staff must maintain a calm passage and display behavior towards patients.
Rational:
Anxiety is contagious and can be transferred from nurses to patients.

(F) Have a staff strong enough physically to help secure the patient if necessary.
Rational:
It is necessary to control the situation and also provide physical security to the staff.

(G) Provide appropriate medication therapy treatment program. Monitor the effectiveness of drugs and their side effects.
Rational:
How to achieve "alternative batasaan least" should be selected when planning interventions for psychiatry.

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Nursing Interventions for Ineffective Breathing Pattern - Pleural Effusion

Pleural effusion is a condition in which the lubrication lining the outside of the lungs builds up and eventually inhibits a person's breathing.

The pleural fluid remains in dynamic equilibrium with blood. Movements of the lung favour the movement of the fluid in and out of the pleural space. In most of the disease states, absorption of the fluid is reduced. The fluid may be contained in the general pleural space or it may be loculated in the interlobar fissure, infrapulmonary space or may remain adjacent to the mediastinum. The fluid progressively compresses the subjacent lung which undergoes collapse.

Although pleural effusion in itself is not a disorder, it is a symptom of several health issues, such as congestive heart failure and malignant cancers like mesothelioma.

Nursing Interventions for Ineffective Breathing Pattern - Pleural Effusion

Nursing Diagnosis: Ineffective breathing pattern related to:

• Decrease in lung expansion (fluid accumulation)
• Muskuluskeletal disorders
• Pain / anxiety
• inflammatory process

characterized by:

• dyspnea, takhipnea
• changes in depth / kesamaanpernapasan
• use of accessory muscles, nasal dilation
• impaired development of the chest and cyanosis, abnormal blood gas analysis

Expected outcomes / evaluation criteria, the client will:

• Showed a normal breathing pattern / blood gas analyzer effectively with the normal range
• There was no cyanosis
• No signs / symptoms of hypoxia.

Nursing Interventions for ineffective breathing pattern - Pleural effusion:

1. Identifying the etiology / factor triggers
Rational: understanding the causes of lung collapse necessary for the proper installation of the chest tube and choose another teraupetik action.

2. Evaluation of respiratory function.
Rational: respiratory distress and changes in vital signs may occur due to physiological stress and may indicate the occurrence of pain or shock.

3. Auscultation of breath sounds
Rational: The sound of the breath can be decreased or no lobe, lung segment or the entire lung.

4. Assess fremitus
Rational: Sound and tactile fremitus (vibration) decreases in fluid-filled tissue / consolidation.

5. Collaboration in the assessment of radiographic series
Rational: hemathorak improvement and monitor progress of lung expansion.

6. Collaboration in the provision of supplemental oxygen through a cannula / mask as indicated.
Rational: A tool in reducing the work of breath, increased respiratory distress and cyanosis relief with respect to hypoxemia.

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5 Nursing Diagnosis for Malaria

Malaria is a serious infectious disease Caused by a parasite That gets into the body when a mosquito carrying the disease bites. Microbial parasites known as Plasmodium. This parasite infects mosquitoes of the Anopheles genus. The female Anopheles mosquito transmits this disease via mosquito bites Among Humans. Out of the eleven species of the genus Plasmodium, five are known to cause malaria Among Human Beings.

Malaria is an infectious disease with periodic fever, caused by the parasite Plasmodium and transmitted by mosquitoes kind Anopeles (Tjay & Prog, 2000).

Symptoms of Malaria

• Some malaria symptoms can seem rather like flu, but malaria can be very serious if it progresses to a lifethreatening coma.
• Symptoms can include:
• Temperature Greater Than 38 ° C
• tiredness
• Chills with sweating
• Muscle aches
• Headache

5 Nursing Diagnosis for Malaria

Nursing diagnosis for malaria, based on signs and symptoms can be described as below (Doengoes, Moorhouse and Geissler, 1999):

1. Imbalanced Nutrition Less Than Body Requirements
related to inadequate food intake; anorexia; nausea / vomiting

2. Risk for Infection related to decreased immune system; invasive procedures

3. Hyperthermia related to increased metabolism, dehydration, a direct effect on the hypothalamic circulation of germs.

4. Impaired Tissue Perfusion related to a decrease in the cellular components needed for the delivery of oxygen and nutrients in the body.

5. Knowledge deficient: the disease, prognosis and treatment needs related to lack of exposure / recall error interpretation of information, cognitive limitations.

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Ineffective Tissue Perfusion Nursing Interventions for Meningitis

Ineffective Tissue Perfusion related to increased intracranial pressure

Definition

Meningitis is an inflammation of the lining of the brain (arachnoid and piamater). Bacteria and viruses are the leading cause of meningitis.

Purpose

• The patient returned to the state of the neurological status before the illness
• Increased patient awareness and sensory function

Expected results:

• Vital signs within normal limits
• Head pain was reduced
• Increased awareness
• An increase in cognitive or loss and no signs of increased intracranial pressure.

Action Plan

Impaired Tissue Perfusion Nursing Interventions for Meningitis

1. Patient's total bed rest with supine sleeping position without a pillow.
Rationale: Changes in intracranial pressure will be able to mislead the risk for brain herniation.

2. Monitor signs of neurological status with a GCS.
Rational: To reduce further brain damage.

3. Monitor vital signs such as BP, pulse, temperature, respiration, and caution in systolic hypertension.
Rational: In the normal state of autoregulation to maintain a state of altered systemic blood pressure fluctuations. Autoreguler failure would lead to cerebral vascular damage can be manifested by an increase in systolic and diastolic pressure followed by a decline. While the increase in temperature can describe the course of infection.

4. Monitor intake and output.
Rational: Hyperthermia can lead to increased IWL and increased risk of dehydration, especially in patients who are not aware, nausea which decreases oral intake.

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

6. Collaboration
Give intravenous fluids with strict attention.
Rationale: Minimizing 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 accompanied by the release of oxygen at the cellular level may lead to ischemic cerebral.

8. Provide appropriate treatment advice doctors
Rational: The therapy is given to decrease capillary permeability, decrease cerebral edema, and lower metabolic cells / consumption and seizures.

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Nursing Care Plan for Self Mutilation - Diagnosis and Interventions

Nursing Diagnosis for Self Mutilation

Risk for self-mutilation related to fear of rejection, the natural feeling depressed, angry reaction, the inability to express feelings verbally, the threat of self-esteem due to embarrassment, loss of jobs and so forth.

Goal :

• Short-term goals: the client will seek the help of staff if there is a feeling like self-mutilation
• Long-term goal: client will not be self-mutilation

Nursing Interventions for Self Mutilation

• Observation of the behavior of clients, more often through routine activities and interactions, avoid the impression of surveillance and suspicion on the client
• Establish verbal contact with the client that he would ask for help if the desire for self-mutilation is felt (to discuss suicidal feelings with people you trust)
• If self-mutilation occurs, wound care not to disturb the client with the cause, do not give positive reinforcement for such behavior (the lack of attention to maladaptive behaviors can reduce repetition mutilation).
• Encourage clients to talk about the feelings he had before this behavior occurs (in order to understand the problem)
• Act as a model in which the right to express anger (suicidal behavior is seen as anger directed at ourselves)
• Remove all dangerous objects from the client environment (the security of clients is a priority for curing)
• Navigate back to the distribution of physical mutilation behavior (physical exercise is a safe way to channel the pent-up tension)
• Commitment of all staff to give spirit to the client
• Give medication according to the result of collaboration, monitor effectiveness, and side effects
• Use of mechanical restrain when circumstances force according to the procedure remains
• Observations restrain clients in every 15 minutes / according to the procedure fixed by considering the safety, circulation, basic needs (safety of clients is a priority nursing)

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Nursing Interventions for Schizophrenia

Nursing Interventions for Schizophrenia

Goal:

1. Set realistic goals with clients.
2. Set the desired outcomes for clients with schizophrenia.
3. Set the desired criteria for the families that have family members with schizophrenia.

Nursing Interventions for Schizophrenia

1. Clients who withdrew and isolation

• Use a self-therapeutic.
• Perform a planned interaction, brief, frequent, and not demanding.
• Plan simple activities one-on-one.
• Maintain consistency and honesty in interactions.
• Gradually encourage clients to interact with their peers in a non-threatening situation
• Provide social skills training.
• Perform a variety of actions to improve self-esteem.

2. Clients show regressive behavior or unfair

• Do approach, it is strange behavior (do not reinforce this behavior).
• Treat the client as an adult, even though the client regresses.
• Monitor the client's diet, and give support and assistance when necessary.
• Assist the client in terms of hygiene and dress up, only when the client can not do it alone.
• Be careful with the touch because it can be considered a threat
• Create a regular schedule of activities of daily living.
• Give a simple choice of two things for clients who experience ambivalence.

3. Clients with no clear pattern of communication

• Keep your own communication to keep it clear and unambiguous.
• Maintain consistency of your verbal and nonverbal communication.
• Clarification of any meaning ambiguous or not clearly related to client communication

4. Clients who are suspicious and rude

• Form professional relationships; too friendly to bet the threat.
• Be careful with the touch because it can be considered a threat.
• Give as much control and autonomy to the client within the therapeutic limits.
• Create a sense of trust through brief interactions that communicate caring and respect.
• Describe any treatment, medication and laboratory tests before the start.
• Do not focus or strengthen the suspicion or delusional ideas.
• Identify and provide a response to the underlying emotional needs of suspicion or delusional
• Intervene when the client shows signs of increasing anxiety and potentially express an unconscious behavior.
• Be careful to not behave in a way that could be misinterpreted kilen.

5. Clients with hallucinations or delusions

• Do not focus on hallucinations or delusions. Perform an interrupt to initiate interaction with the client's hallucinatory one-on-one based on reality.
• Tell them that you do not agree with the perception of the client, but the validation that you believe that the hallucinations are real to the client.
• Do not argue with the client about the hallucinations or delusions.
• Respond to the feelings that are communicated to the client when he was having hallucinations or delusions.
• Switch and the client focus on a structured activity or task-based reality.
• Move the client to a more quiet, less stimulating.
• Wait until the client does not have hallucinations or delusions before starting the counseling session about it.
• Explain that hallucinations or delusions are symptoms of psychiatric disorders.
• Say that the anxiety or increased stimulus from the environment, to stimulate the onset of hallucinations.
• Help clients to control hallucinations by focusing on reality and take medication as prescribed.
• If hallucinations persist, Bantu clients ignore it and continue acting remedy properly despite a hallucination.
• Teach a variety of cognitive strategies and tell the client to use self talk ("voices that makes no sense") and the cessation of the mind ("I will not think about it").

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How to Prevent a Broken Spirit

A broken spirit, must be prevented if people want happiness and success. This understanding should then be followed by self-awareness about personal values ​​and interpret their personal experiences in practice. Realizing the high demand for personal success, along with strong attention and responsibility on the athlete should be considered as the main symptom onset discouraged. With self-awareness, can begin to use this power to the power of their success without neglecting their needs and behavior. Obtain a healthy balance among fellow athletes, family and personal needs of the board is an essential step in order to overcome a broken spirit.

1. Maintain a proper perspective
Maintaining a correct view of a lot of benefits. If you suffer from severe stress, it will tend to think of the demands of time, energy spent, complaints from parents. But if you are able to consciously focus on the problems encountered in many other careers, it will be able to take benefit from it.


2. New Environment
Another approach to overcome the discouragement that is looking for new work. For that purpose must be careful to recognize the advantages and disadvantages of the new position. They must be confident that they will be more happy, and not less happy in addition, sometimes a new environment will be many benefits.

3. Family Support
Many were able to escape from the stress of continuous through unlimited support from parents, families and close friends. Often parents participate in sports to avoid loneliness continuously. Sometimes parents or boyfriend serves as a sports photographer, recording the value or the head of public relations. Interactions are very familiar with the team members can draw the attention of parents. You often get huge support from his family. A family that is ready to listen and discuss the problems encountered if the child can actively resist the pressure and accept the situation himself. Although progress is continually striving to him they are proud of what they played in every game. Ego demands that the state will be happy diirinya a positive impact and not cause a positive influence.

4. Be proud of yourself
Proud of himself would not try even become someone else, and believes that implementation would bring success. People who feel unhappy with his situation was a happy and fun people, and parents with the community. The result, usually have high motivation. They are happy and confident.

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Nursing Assessment and Nursing Diagnosis for Headaches

Nursing Assessment for Headaches

Subjective and objective data is essential to determine the causes and nature of the headache.

1. Subjective Data

• Understanding the patient about headaches and possible causes.
• Aware of the existence of trigger factors, such as stress.
• Measures to reduce symptoms such as drugs.
• Place, frequency, pattern and nature of the place of pain including headache, duration and interval between headaches.
• Beginning of the headache attacks.
• There are symptoms or not prodomal
• There are accompanying symptoms.
• Family history of headaches (especially important when a migraine).
• The situation is made more severe headaches.
• There is an allergy or not.

2. Objective Data

• Behavior: showing symptoms of stress, anxiety or pain.
• Changes in the ability to perform daily activities.
• There is an abnormal assessment of the physical assessment of cranial nerve system.
• Body temperature
• Drainage of the sinus.

In the assessment of headache, a few important things to consider. Among them are:

• Localized headaches usually associated with migraine headaches or organic disorders.
• Headaches are usually caused by complete or psychological causes of increased intracranial pressure.
• Migraine headaches can move from one side to the other.
• Headaches are accompanied by an increase in intracranial pressure usually occurs during sleep or waking headaches wake patients from sleep.
• Type headache sinuses arise in the morning and the afternoon to get worse.
• A lot of headaches associated with stress conditions.
• The pain is dull, annoying, escalate and continue to exist, often occurs in the psikogenis headache.
• Organic materials that cause pain and its still growing steadily.
• Migraine headaches can accompany menstruation, headaches can be preceded by eating foods that contain monosodium glutamate, sodim nitrate, tyramine as well as alcohol.
• Sleeping too long, fast, inhaling the toxic odors in the workplace where insufficient ventilation can cause headaches.
• Oral contraceptive medications can aggravate migraines.
• Each found the secondary of a headache needs to be studied.

Nursing Diagnosis for Headaches

1. Acute pain r/t stess and tension, irritation / nerve pressure, vasospasm, increased intracranial pressures.

2. Ineffective individual coping r/t situations of crisis, personal vulnerability, not adequat support systems, work overload, inadequate relaxation, severe pain, excessive threat to himself.

3. Deficient knowledge : about the condition and treatment needs r/t lack of recall, did not know the information, cognitive limitations.

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Nursing Diagnosis and Interventions for Cerebral Palsy

Cerebral Palsy is a condition lasting damage to brain tissue and not progressive, occurring in a young (since birth) and hinder normal brain development with clinical manifestations may change throughout life and showed abnormalities in the attitude and movement, accompanied by neurological abnormalities in the form of spastic paralysis, ganglia disorders, basal, cereblum and mental disorders.

Nursing Diagnosis for Cerebral Palsy

a. Risk for injury r/t spasms, uncontrolled movements and seizures

b. Impaired Physical mobility r/t spasms and muscle weakness.

c. Changes in growth and development r/t neuromuscular disorders.

d. Impaired verbal communicationr/t difficulty in articulation.

e. Risk for aspiration r/t neuromuscular disorders

f. Changes in thought processes r/th cerebral injury, learning disabilities.

g. Self-care Deficit r/t muscle spasms, increased activity, cognitive changes.

h. Deficient Knowledge r/t home care and therapeutic needs.

Goal :
a. Children will always be safe and free from injury.
b. Children will have a maximum movement ability and not have contractures.
c. Children will explore how to learn and participate with other children in doing some activities.
d. Children will express their needs and develop a body weight within normal limits.
e. Children do not have aspirations.
f. The child will demonstrate an appropriate level of learning ability.
g. Daily needs of the child tetpenuhi.
h. Parents / family demonstrate understanding of the needs of child care that is characterized by taking an active role in child care.
i. Children do not show a marked impairment of skin integrity with intact skin.


Nursing Interventions for Cerebral Palsy

a. The increasing need for security and prevent injury

1) avoid children from harmful objects, for example can be dropped.
2) watch the children during activity.
3) give the kids a break when tired.
4) use safety equipment when necessary.
5) when a seizure; install a safety device in the mouth so that the tongue is not bitten.
6) do suction.
7) the provision of anti-seizure in the event of a seizure.

b. Improve the physical mobility

1) examine the movement of the joints and muscle tone.
2) do physical therapy.
3) do repositioning every 2 hours.
4) evaluation of the needs of special equipment for eating, writing and reading and activities.
5) teach the use of a walker.
6) teach how to sit, crawl in young children, walking, and others.
7) teaches how to reach for objects.
8) taught to move the limbs.
9) teach appropriate ROM.
10) provide a rest period.

c. Increases the need rumbuh flowers in the optimum level

1) examine the growth and development.
2) teaching for early intervention with therapeutic recreation and school activities.
3) Provide appropriate activities, withdrawal and can be done by a child

d. Improve communication

1) examine the response to communication.
2) use the cards / pictures / whiteboards to facilitate communication.
3) Involve the family in training a child to communicate.
4) refer to a speech therapist.
5) teach and assess non-verbal meaning.
6) trained in the use of the lips, mouth and tongue.

e. Improve the nutritional status needs

1) examine the diet of children.
2) Weigh weight every day.
3) provide adequate nutrition and food preferences, lots of protein, minerals and vitamins.
4) Give extra foods that contain lots of calories.
5) Help your child meet their daily needs with the ability

f. Prevent the occurrence of aspiration

1) do immediately when there is suction secretions.
2) provide an upright position or semi-sitting while eating and drinking.
3) examine the pattern of breathing

g. Increase the need for intellectual

1) review the child's level of understanding.
2) teach in understanding conversations with verbal or non verbal.
3) teach writing using whiteboards or other devices that can be used according to the ability of parents and children.
4) teaching reading and writing according to his needs

h. Meet the daily needs

1) examine the level of children's ability to meet daily needs.
2) assist in meeting the needs; eating and drinking, elimination, personal hygiene, dress, play activities.
3) Involve families and for children who are cooperative in meeting their daily needs.

i. Enhance the knowledge and the role of parents in meeting child care needs

1) examine the level of parental knowledge.
2) teach parents to express their feelings about the child's condition.
3) teach parents in meeting child care needs.
4) teach about the conditions experienced by children and are related to physical therapy and exercise needs.
5) emphasize that parents and families have an important role in helping meet the needs.
6) explain the importance of play and socialization needs of others.

j. Prevent to impaired skin integrity

1) examine the area that is attached ancillary equipment.
2) use a skin lotion to prevent dry skin.
3) do the massage in a depressed area.
4) provide a comfortable position and provide support with pillows.
5) ensure that ancillary equipment or dressing appropriately and fixed.

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Family Nursing Process In Hypertension Patients

According to Bailon and Maglaya (1978:2) in the nursing process there are various forms of family health nursing process in which the family health care is the level of public health care is addressed or focused on the family as the smallest unit or a single entity and treated, with a sense as a goal and through health care as the ingredients. Meanwhile, according to Effendi (1998:46) The nursing process is a scientific method that is used systematically to assess and determine the issues of health and family nursing, nursing care plan and implement interventions to families in accordance with the plans that have been compiled and evaluated the quality of nursing care is carried out against family.

Family nursing process there are several steps that are systematically arranged to illustrate the progression from stage to stage. According to Friedman (1998: 55) divided into five stages of the nursing process which consists of an assessment of the family, the identification of an individual or family problems and nursing diagnoses, treatment plans, deployment plans implemntasi sources and evaluation of care.



Family Nursing Process In Hypertension Patients

Nursing Assessment

Nursing assessment is the stage when a nurse is continuously collecting information about the family cultivated. Nursing assessment is the first step in the implementation of family nursing care. In order to obtain an accurate assessment data and in accordance with family circumstances, nurses are expected to use their mother tongue (the language used in everyday life), straightforward and simple.

Activities undertaken in the assessment includes the collection of information in a systematic way by using a family assessment tool, classified and analyzed.

Data Collection On Patients Hypertension

1) Assessment of family identity are: age, occupation, residence, and family type.

In general, patients with hypertension is a disease that is influenced by lifestyle, especially the wrong lifestyle, lifestyle-related negative emotions, such emotions are uncontrollable or temperamental, ambitious, hard worker who is not calm, excessive fear and anxiety.

2) Cultural background / family practice
a. Eating habits
Eating habits include the type of food consumed by the family. In families with hypertension often found improper diet such as eating foods that contain lots of preservatives, the food is salty and negative emotions.

b. Utilization of health facilities
Family behavior in the use of health facilities is an important factor in the management of hypertension. The existence of health care resources are used for prevention and early treatment as it can prevent the onset of complications. (Rokhaeni, 2001:115).

c. Traditional medicine
Families can treat hypertension with traditional medicine, namely drinking juice garlic finely ground and given to drink enough water in the morning and afternoon (Hariadi, 2001:26). Hypertension will become worse and cause complications if the patient does not choose the traditional treatment of hypertension is right and proper it will aggravate and even cause problems in other organs such as liver, kidney and stomach.

3) Socioeconomic Status
a. Education
Family education level affects the family in identifying hypertension and its management. also affect the pattern of thought and the ability to take decisions to tackle the problem properly and correctly.

b. Employment and Income
Unequal income also affects the family in treatment and care to sick family members one of which is caused due to hypertension.

4) The development and family history
Family history from birth to the present. Includes history and development of events and experiences unique health or health-related that occurred in family life unmet psychological effect on a person that can lead to anxiety stress.

5) Activity
Hard physical activity can add to the increase in blood pressure. Hypertension may occur after an attack or when doing physical activities, like sports.

6) Environmental Data
a. characteristics of home
Way modify the physical environment such as the floor of the house is good, good lighting and ventilation factors can lessen the causes of hypertension as well as peace in the household can reduce hypertension attack.

b. Environmental characteristics
According to (friedman, 1998: 22) is influenced by the degree of environmental health. Peace of the environment strongly influences the degree of health is no exception in hypertension

c. Family gatherings and interaction with the community
Problems in the family may be one factor which triggers the occurrence of hypertension will lead to anxiety is a risk factor for hypertension.

7) Family Structure
a. communication patterns
According to (Nursalam, 2001:26) All nurse interaction with patients is based on communication. The term communication is a technique in which teurapetik effort to invite patients and families to exchange ideas and feelings. Engineering skills include verbal and non verbal, empathy and a sense of high concern.

b. The power structure
Power within the family affect the health conditions, authoritarian rule can lead to psychological stress affect the hypertension.

c. The structure of the role
When family members received and made ​​consistent with the role, then this will make the family members are satisfied or not there is conflict in the role, and vice versa when a role is unacceptable and incompatible with the hope it could lead to tensions within the family (Friedman, 1998).

9) The pattern of rest-sleep
Restful sleep will be disturbed when someone is experiencing unresolved problems. In patients with hypertension, sleep disorders are often caused by a break shortness of breath and coughing. Unmet need for bed rest are at risk of worsening the state of hypertension.

10) The physical examination of family members
As a comprehensive assessment procedure, also performed a thorough physical examination from head to nail. Once found health problems, physical examination focused more on examining the respiratory system, especially in patients with hypertension due to the presence of hypertension may increase intra-cranial pressure which can cause abnormalities in the respiratory nerves.

11) Family Coping
If there are stressors in the family, whereas family coping is ineffective, then this will be a family member to prolonged stress. One of the prevention of hypertension attacks are not often appear to prevent the onset of stress (Cape, 2003).

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