Saturday, June 30, 2012

Effective Cough - Definition, Purpose and Method

Definition of Effective CoughDefinition, Purpose of Effective Cough and Method of Effective Cough

Definition of Effective Cough

Effective cough is a necessary action to clear secretions. (Hudak & Gallo, 1997:494).

Coughing is also a common symptom of respiratory disease. Stimuli that normally cause a cough is the stimulation of mechanical, chemical and inflammation. Each of the respiratory tract inflammation with or without exudate can lead to cough. Chronic bronchitis, asthma, tuberculosis (pulmonary tuberculosis) and pneumonia is a disease that typically have a cough as a symptom of which is striking. (Wilson, 2006:773-774)

Indications of Effective Cough

According to Wilson (2006:773-774) Effective Cough, performed on patients such as:
  1. Chronic bronchitis
  2. Asthma
  3. Pulmonary tuberculosis (TB).
  4. Pneumonia
  5. Emphysema
Purpose of Effective Cough

Effective coughing and deep breathing is an effective cough techniques which emphasize maximal inspiration, the beginning of expiration, which aims to:
  1. Stimulate opening collateral system.
  2. Improve the distribution of ventilation.
  3. Increase lung volume and airway to facilitate cleaning. (Jenkins, 1996)
  4. Increase lung expansion.
  5. Mobilization of secretions.
  6. Prevent the side effects of secretion retention (pneumonia, Ateletaksis and fever).
(Hudak & Gallo, 1997:494)

Method of Effective Cough
  1. Sit up straight.
  2. Then inhale deeply, 2 times slowly through your nose and exhale through the mouth.
  3. Inhale the third time and hold your breath for a count to 3, with a strong cough 2 or 3 times in a row without having to inhale again during coughing.
  4. Continue to exercise as much as 2-3 times cough on waking.
  5. Repeat as needed.
(Bangerd, 2011)

Definition, Causes, Signs and Symptoms of Urinary Tract Infection

Definition of UTI, Causes of UTI, Signs and Symptoms of Urinary Tract InfectionDefinition and Causes of Urinary Tract Infection (UTI)

Urinary Tract Infection (UTI) is a condition of inflamed urinary system due to bacterial infection. The infection generally starts from the estuarine section urinary infection and the urethra (urethritis) but if not addressed properly then the infection will spread to the bladder (cystitis), ureters (urethritis) and even up to the kidneys (pyelonephritis) (Suciadi, 2010:34).

The types of microorganisms that cause UTI, according to Sudoyo (2006:564) are:
  1. Escherichia Coli: 90% of the cause of uncomplicated UTI (simple)
  2. Pseudomonas, Proteus, Klebsiella: the cause of complicated UTI
  3. Enterobacter, staphylococcus epidemidis, enterococci, and-others.
Trigger UTI in the elderly by Tessy (2001) are:
  1. The remaining urine in the bladder is increased due to the emptying of the bladder is less effective.
  2. The mobility decreases.
  3. Nutrition is often poor.
  4. Decreased immune system, both cellular and humoral.
  5. The existence of barriers to the flow of urine.
  6. Loss of bactericidal effect of secretions of the prostate.
Signs and symptoms of Urinary Tract Infection (UTI)
  1. The pain during urination.
  2. Acute Pain : Abdominal pain and lower middle.
  3. Colored urine is cloudy and there was blood.
  4. Low back pain.
  5. Fever to chills.
  6. Nausea and vomiting.
Signs and symptoms of UTI at the bottom, according to Smeltzer (2008), namely:
  1. Pain is a frequent and burning sensation when urinating.
  2. Spasm in the bladder and suprapubic area.
  3. Haematuria.
  4. Back pain can occur.
Signs and symptoms of upper UTI, according to Smeltzer (2008), namely:
  1. Fever and chills.
  2. Pelvic and hip pain.
  3. Pain when urinating.
  4. Malaise and dizziness.
  5. Nausea and vomiting.
Prevention of Urinary Tract Infection (UTI)
  1. Get used to drinking enough water each day, which is 8 glasses a day.
  2. Avoid the habit of holding urine.
  3. For women, avoid the habit of washing the genitals with a variety of cosmetic products that are not clear or wipe with toilet water of questionable cleanliness.
  4. Get used to wipe with the direction from front to rear direction.
  5. Get used to relate in a healthy way, women should get used to urinate after intercourse.
  6. Keep your genital area.
  7. Replace the pads when you are menstruating regularly.
  8. Replace regular diaper.
  9. Wear underwear made ​​from a comfortable and not too tight
  10. Check urine regularly during pregnancy.
  11. Complete treatment if you have prostate disease or urinary tract stones.
(Suciadi, 2010:65).

How to Resolve Complaints of Menopause and How to Slow Down of Menopause

How to Resolve Complaints of Menopause and How to Slow Down of Menopausea. Complaints arising from changes in menopause can be treated with drugs that are replacing the functions of estrogen. It aims to repair cells that suffered a setback.

b. Consuming vitamin that serves to inhibit the aging process.

c. Adequate exercise and age-appropriate is one way to nourish the physical. With exercise the body will be protected from diseases that are vulnerable in the face by the elderly.

d. Eat a balanced diet and as needed, avoid fatty foods. Expand to eat vegetables and fruits that can help the body's metabolic processes.

e. Doing a hobby that can support health can make distracting from menopausal complaints.

f. Keep working for menopausal women to maintain a sense of confidence.

g. Engage in social religious activities.

h. Familiarization with the environment.

i. Get together with people who have similar problems to a variety of experiences and knowledge.

j. Communicate with her ​​husband and family so they can provide good support.

Menopause

Nutrients that can help reduce menopausal complaints:

1) Omega 3 fatty acid that serves to prevent the occurrence of depression.

2) Folic acid works to prevent the occurrence of depression.

3) Iron to increase blood hemoglobin.

4) Calcium to reduce complaints of hot flushes and osteoporosis.

5) Vitamin D to reduce the complaints of the skin and bones.

6) Sources: Fatty fish, green leafy vegetables, orange juice, red meat, beans, spinach, raisins, cereal. Low-fat milk and other dairy products, canned fish, anchovies, tuna, salmon, etc..

The main treatment of the menopause is to provide external terapy hormone estrogen known as Hormone Replacement Therapy (HRT). Principles of administration are:

a. Women who still have a uterus, given the combination of estrogen and progesterone, the addition of progesterone is intended to avoid the risk of endometrial cancer.

b. Women who had been without a uterus, estrogen is given alone to continue.

c. Who are still menstruating woman, estrogen is given in a sequential way.

d. Women who still want occur menstruation, given a continue.

e. Types of estrogen and progesterone that is given is natural.

f. Early provision should be provided with a low dose.

Menopause sometimes make most women become anxious, when in fact it need not be feared, since the onset of menopause can actually slow down the setting up and start living healthy. Preparations include:

a. Exercise regularly and continuously to improve physical strength and bone strength. Exercise you can do include walking, jogging and calisthenics.

b. Eating foods that contain lots of calcium may reduce the risk of bone loss or osteoporosis. Calcium is found in many high-calcium milk, many in high-calcium found in milk, cheese and nuts.

c. Eating foods that contain lots of vitamins to improve health and endurance. Vitamins are found in vegetables and fruits.

d. Reduce the consumption of drinks that contain lots of caffeine, for example, include coffee, tea and soft drinks. Because these drinks can inhibit the absorption of calcium and iron.

e. Not consume alcohol and cigarettes because both of these can accelerate the occurrence of menopause and boost the risk of osteoporosis.

f. Eating foods that contain lots of calcium may reduce the risk of bone loss or osteoporosis. Calcium, cheese and nuts.

g. Consuming a lot of eating
(Wahyunita, 2010:100)

Definition, Causes, Classification and Pathophysiology for Epilepsy

Definition, Causes, Classification and Pathophysiology for EpilepsyDefinition, Causes, Classification and Pathophysiology for Epilepsy

Epilepsy or epilepsy known as the "world's oldest diseases" (2000 years BC). The disease is fairly common and is chronic. Patients will suffer for years. About 0.5 - 1% of the population are people with epilepsy.

Definition of Epilepsy

Rise of epilepsy, are manifestations of brain disorders with different clinical symptoms, caused by loss of electrical charge from brain neurons to excess and periodic but reversible with various etiologies (Tjahjadi, et al, 1996).

Epilepsy is a complex symptom of several disorders of brain function characterized by the occurrence of repeated seizures. Can be associated with loss of consciousness, excessive movement, or loss of muscle tone or movement, mood and behavior disorders, sensation and perception (Brunner and Suddarth, 2000).

Seizures are the release of a group of neurons suddenly resulting in the destruction of consciousness, movement, sensation or temporary memory. The term epilepsy is usually a chronic disorder that is incurred as a form of repetitive strain (Hudak and Gallo, 1996).

Pathophysiology for Seizure EpilepsyCauses of Epilepsy

The most significant cause for epilepsy and seizures is considered as head trauma. Even though it has been widely accepted that when a remote injury which has occurred in previously could cause epilepsy, well there's no confirmation given as to how long or what kind of this injury should be. However, it is commonly known that epilepsy risk can boost up substantially when there're penetrating or say, open wound.

Tonic clonic seizures - This considered to be extremely intense among every kind of seizures, they could be characterized through lack of consciousness, body shivering and stiffening and have no control on bladder or at times tongue biting.

If every brain's area is disturbed by non-standard electrical activity, then it might result in generalized seizure. It means that their lack of consciousness or may be consciousness is impaired. Frequently every individual's legs and arms stiffen and later jerk rhythmically.


Pathophysiology of Epilepsy

The exact mechanism of seizure activity in the brain are not everything can be understood. Some triggers cause a sudden burst of abnormal electrical stimulation, the brain disrupt normal nerve conduction. In the brain that are not susceptible to seizures, there is a balance between excitatory and inhibitory synaptic neurons that affect postsinaptik. In the brain that are susceptible to seizures, the balance is disrupted, causing an imbalance of electrical conduction pattern of the so-called paroxysmal depolarization shift. This shift can be seen best when there is excessive excitatory effect or inhibitory effect is not sufficient.

Classification of Epilepsy
  1. Partial seizures
    • Simple partial (consciousness of good clients)
      • motor
      • sensory
      • autonomy
      • physical
    • Complex partial (impaired consciousness)
      • Simple partial followed by a decrease in consciousness
      • Awareness at the onset of damage
    • Secondary generalization of partial seizures
  2. General seizures
    • Non seizures
    • General tonic-clonic
    • Tonic
    • Clonic
    • Myoclonic
    • Atonik
  3. Seizures Not classified

Tuesday, June 26, 2012

2 Nursing Diagnosis Interventions for Anemia

Nursing Care Plan Anemia Diagnosis InterventionsNursing Care Plan for Anemia

Anaemia
is a condition in which the number of red blood cells or their oxygen-carrying capacity is insufficient to meet physiologic needs, which vary by age, sex, altitude, smoking, and pregnancy status.

There are several types and classifications of anaemia. This is a condition in which the body lacks the amount of red blood cells to keep up with the body's demand for oxygen.

Symptoms of Anemia

According to John Hopkins Point-of-Care Information Technology Center, (The John Hokins POC-IT Center), the most common causes of anemia include:
  • dizziness,
  • weakness and fatigue,
  • shortness of breath with activity,
  • dizziness,
  • occasional chest pains, and
  • cold, clammy skin.
Having nerve pain may also point to the presence of this problem.

Causes of Anemia

There are several causes of anemia, which include:
  • Iron deficiency
  • Kidney disease
  • Pregnancy
  • Poor nutrition
  • Deficiency of vitamin B12 known as pernicious anemia
  • Sickle cell anemia
  • Thalassemia
  • Alcohol
  • Bone marrow related anemia
  • Aplastic anemia
  • Hemolytic anemia
  • Active bleeding, eg. heavy bleeding during menstration.
Treatments of Anemia

Once the doctor determines the cause he or she will initiate a treatment program for you. Here are some causes along with their treatment protocol. Blood Loss: the source of the bleeding will be determined and stopped. For example you may be given a blood transfusion and iron to build up your red blood cell count. Iron Deficiency: If you have inadequate iron levels you most likely will be prescribed iron supplements.

Do not do this on your own but under the care of a physician because consuming too much iron can be dangerous. Red blood cell destruction: Known as hemolytic anemia, there are various causes for it. So the treatment would of course depend on the cause. Follow up care: You need to stay under your doctor's care and have repeated blood work done to determine if the anemia has gone away. Your response to the treatments prescribed will determine what the next steps are to take. The hopeful outcome is that you have overcome your anemia.

If not, with continued care over time you should be able to do so. Before doing any dietary or lifestyle changes always consult with your health care provider, particularly if you have been diagnosed with a disease or are taking any prescription medication.


2 Diagnosis Nursing Interventions for Anemia

1. Ineffective Tissue Perfusion

Objectives:
  • Adequate tissue perfusion
Nursing Intervention for Anemia :
  • Monitor vital signs, capillary refill, skin color, mucous membranes.
  • Exalt the position of head of in bed
  • Examine and document the presence of pain.
  • Observation of a delay in verbal response, confusion, or restlessness
  • Observe and document the presence of the cold.
  • Maintain the ambient temperature to keep warm the body needs.
  • Provide oxygen as needed.

2. Activity Intolerance

Objectives:
  • Tolerant of activity
Nursing Intervention:
  • Assess the capability of doing the activity
  • Monitor vital signs during and after activity, and noted a physiological response to activity (increased heart rate increased blood pressure, or rapid breathing).
  • Provide information to the patient or family to stop doing activities if teladi symptoms of increased heart rate, increased blood pressure, rapid breathing, dizziness or fatigue).
  • Provide support to perform their daily activities according to the ability of the child.
  • Creating a schedule of activities involving other health team.


Related Articles :
Nursing Diagnosis for Anemia
Nursing Intervention for Anemia
Nursing Care Plan for Anemia
Management of Anemia
NCP for Anemia
Ineffective Tissue perfusion related to Anemia
Nanda Anemia

Saturday, June 23, 2012

3 Nursing Diagnosis and Interventions for Hepatitis

Nursing Care Plan Diagnosis Interventions HepatitisHepatitis is a class of diseases That impact the liver. Hepatitis can cause inflammations of the liver and can cause its function to diminish. When this Happens liver scarring can occur, the which is known as cirrhosis, and in severe cases, cancer can develop. Hepatitis can be attributed to Certain types of medication, toxins, alcohol, hereditary conditions, viruses, and autoimmune disorders. Hepatitis can be classified as viral or non viral.

There are five types of viral hepatitis to play, and each has Their Own transmission methods, effects, and symptoms. These five types are categorized, A, B, C, D, and E. The most common of these types are A, B, and C.

In the viral hepatitis and non viral forms may show mild, moderate, or severe symptoms. Some Patients may not show any symptoms at all. Fatigue is usually the only symptom in very mild cases. Other symptoms include: jaundice, headaches, fever, joint pain, muscle aches, a lack of appetite, pale stools, dark urine the color of tea, vomiting, nausea, abdominal pain, diarrhea, drowsiness, circulatory problems, and dizziness.


3 Nursing Diagnosis and Interventions for Hepatitis


1. Nursing Diagnosis: Acute Pain related to swelling of the liver is inflamed.

Expected outcomes :
  • Showed signs of physical pain and pain behavior (do not wince in pain, cry intensity and location)
Nursing Interventions for Acute Pain - Nursing Care Plan for Hepatitis:
  • Collaboration with patients, to determine the method can be used for pain intensity.
  • Indicate the client's acceptance of the client's response to pain
    • Acknowledge the pain.
    • Listen attentively to the client about pain expression.
  • Provide accurate information and explain the causes of pain, how long the pain will end, if known.
  • Discuss with your doctor the use of analgesics that do not contain hepatotoxic effects.

2. Nursing Diagnosis : Ineffective Breathing Pattern related to intra-abdominal fluid collections, ascites decreased lung expansion and accumulation of secretions.

Expected outcomes :
  • Adequate breathing pattern
Nursing Interventions for Ineffective Breathing Pattern - Nursing Care Plan for Hepatitis:
  • Monitor the frequency, depth and respiratory effort
  • Auscultation of breath sounds additional
  • Give the semi-Fowler position
  • Give a deep breath and coughing exercises effective
  • Give oxygen as needed

3. Nursing Diagnosis: Imbalanced Nutrition Less Than Body Requirements related to failure to meet the metabolic needs of entry: anorexia, nausea / vomiting and disturbances of digestion absorption and metabolism: a decrease in peristalsis (visceral reflex), retained bile.

Expected outcomes :
  • The patient will show behavioral changes in lifestyle to improve / maintain appropriate weight.
  • Patients will show improvement with a goal weight and value-free laboratory signs of malnutrition.
Nursing Interventions Imbalanced Nutrition Less Than Body Requirements - Nursing Care Plan for Hepatitis
  • Monitor the inclusion of diet / calories. Give a little meal in the frequency often, and offer the greatest breakfast.
  • Provide oral care before meals.
  • Encourage eating in an upright sitting position.
  • Encourage intake of orange juice, beverage and candy carbonate heavy throughout the day.
  • Consult an expert on diet, nutrition support teams to provide appropriate dietary needs of patients, with the input of fat and protein as tolerated.
  • Keep an eye on blood glucose.
  • Give extra food / nutrient total support when needed.

Saturday, June 2, 2012

Nursing Diagnosis and Interventions for Jaundice

Nursing Care Plan for JaundiceJaundice is a yellow discoloration of the skin, the mucous membrane and the white of the eyes. Jaundice is most commonly found in babies and newborns. Jaundice newborn is an infant with a condition caused by the extensive amount of bilirubin in blood.

Jaundice newborn represents a large group of newborns, approximately 60% of full term (physiological or normal jaundice) and 90% of premature babies (jaundice of prematurity). There is also breastfeeding jaundice which occurs when a newborn is not getting enough milk to drink.

There are a number of possible causes for jaundice in babies and newborns. The most common cause is over-feeding with breast milk. Since the baby's liver is too small, it can rarely cope with the enzymes, present in the milk, especially if the baby is overfed. Other causes include diseases, anemia, or a physical defect in the liver.

Newborn jaundice usually lasts 10 -14 days and it retreats in reverse to the development process, legs looking normal first leaving the little face colored the longest. This process can last up to one month in the premature babies. The same may occur in the breast- fed babies, where the substances contained in mother's milk cause slower development of the enzymes responsible for the digestion of the bilirubin. This condition is called breast milk jaundice and it may take up to 12 weeks to improve.


Nursing Diagnosis for Jaundice and Nursing Intervention for Jaundice

1. Deficient Fluid Volume related to inadequate fluid intake, photo-therapy, and diarrhea.

Goal:
Adequate neonatal body fluids

Intervention:
  • Record the number and quality of stools,
  • Monitor skin turgor,
  • Monitor intake output,
  • Give water between breast-feeding or give bottle.

2. Hyperthermia related to the effects of phototherapy

Goal:
The stability of the baby's body temperature can be maintained

Intervention:
  • Give a neutral ambient temperature,
  • Keep the temperature between 35.5 ° - 37 ° C,
  • Check vital signs every 2 hours.

3. Impaired skin integrity related to hyperbilirubinemia and diarrhea

Goal:
The integrity of the baby's skin can be maintained

Intervention:
  • Assess skin color every 8 hours,
  • Monitor direct and indirect bilirubin,
  • Change position every two hours,
  • Massage the area that stands out,
  • Keep skin clean and moisture.

4. Anxiety related to medical therapy given to the baby.

Goal:
Parents know about treatment, symptoms can be identified to deliver the health care team.

Intervention:
  • Review knowledge of the client's family,
  • Give the cause of yellow health education, therapy and treatment process.
  • Give health education on infant care to home.

Nursing Diagnosis for Stomach Cancer

Nursing Care Plan for Stomach CancerStomach cancer or gastric cancer is a disease in which tumors are found in the stomach. Stomach cancer is common throughout the world and affects all races, it is more common in men than women, and has its peak age range between 40 and 60 years old. If it is not diagnosed quickly, it may spread to other parts of your stomach as well as to other organs. There are twice as many males with this disease than females. The majority of people with stomach cancer are between fifty and seventy years old. It is more prevalent in Japan, Korea, Great Britain, South America and Iceland than in the United States.

Signs and Symptoms of Stomach Cancer

Nausea and vomiting

Nausea and vomiting are symptoms that you can find in almost any disease not just in digestive system disorders. The reason that it is on this list is because nausea and vomiting, as related to stomach cancer, might also be caused by tumor growth. Persistent nausea and vomiting can also cause trauma to your esophagus.

Abdominal Pain

This pain could be caused by the growth of a tumor in your stomach. Usually with stomach cancer, the pain is somewhere near the upper part of your stomach and can either be persistent or intermittent.

Anorexia

Anorexia also known as loss of appetite. Not being hungry for a day to two might be considered normal, but if it persists for more than that, it could be a serious problem. Take note that anorexia, or loss of appetite, is not a telltale sign of cancer alone. It could also be an indicator of other diseases.

Unintended weight loss

Now, a lot of people have been wondering just why a patient with cancer seems to tend to lose weight even without trying. The answer to that is simple. The cancer cells take in the nutrients that are really meant for the body. In essence, they are the ones getting healthier while the body suffers.

Causes of Stomach cancer

The exact cause is unknown although the presence of the Helicopter pylori bacterium seems to be a major factor. Predisposing factors include environmental influences such as smoking and high alcohol intake. Because stomach cancer is more common amongst those with a family history and with people with type A blood, genetic factors are also implicated. Dietary factors, particularly methods of food preservation such as pickling, smoking or salting also have an influence on the prevalence.

Types of Stomach cancer

There are several different types of stomach cancer, some of which are very rare. The most common types start in the glandular cells of the stomach lining (adenocarcinomas), this is where stomach acid and digestive enzymes are made, and where most cancers start. When the tumor becomes more advanced, it can travel through the bloodstream and spread to organs such as the liver, lungs, and bones. Cancers that start in the lymphatic tissue (lymphoma), in the stomach's muscular tissue (sarcoma) or in the tissues that support the organs of the digestive system (gastrointestinal stromal tumors) are less common and are treated in different ways.


Nursing Diagnosis for Gastric Cancer

Preoperative

1. Acute pain related to the growth of cancer cells

2. Anxiety related to plan surgery

3. Imbalanced Nutrition Less Than Body Requirements related to nausea, vomiting and no appetite

4. Activity intolerance related to physical weakness.

Postoperative

1. Ineffective breathing pattern related to the influence of anesthesia.

2. Acute pain related to interruption of the body secondary to invasive procedures or surgical intervention.

3. Imbalanced Nutrition Less Than Body Requirements related to fasting status.

4. Risk for infection related to an increased susceptibility secondary to the procedure.

Friday, June 1, 2012

Nursing Care Plan for Elderly

Nursing Diagnosis for ElderlyAssessment - Nursing Care Plan for Elderly

a. The identity of the patient
Include name, age, sex, religion, education, nation, and address.

b. Disorder found in elderly
Swallowing, communication, pain and others.

c. Mood, consciousness
Hostility, sleep disturbances, and others.

d. History of major problems
Ever stroke, cough, dementia, fractures.

e. Questionable health habits
Smoking, alcohol, and others.

f. Assessment system
Assessment system implemented in sequence starting from system requirements to the musculoskeletal system.

g. History of treatment
Well before the illness, drugs in drinking, both from a doctor's prescription or purchased free (including herbs).

h. Examination of the function
  • Activities of daily living that require only simple body's ability to function such as sleeping, dressing, bathing.
  • Activities of daily living
  • In addition to basic skills that require different coordination ability of the muscle, the more nervous as well as various organs of other cognitive abilities.
  • The ability of mental and cognitive function, especially regarding the intellect, memory and long memory about things that just happened.

Nursing Diagnosis for Elderly

1. Risk for injury: falls related to increased activity.
2. Acute pain: (headaches / dizziness) associated with fatigue.
3. Activity intolerance related to imbalance of O2 supply: weakness.
4. Risk for infection related to the state of nutrition: state of immunity.


Nursing Interventions for Elderly


1. Risk for injury: falls related to increased activity.

Goal:
The client does not fall.

Intervention:
1. Explain to the client about the causes of rheumatic pains / aches.
R /: to understand the causes of line / curve.
2. Provide non-pharmacological measures to eliminate fatigue in the legs such as massage.
R / can stimulate pain in the leg.
3. Avoid doing heavy activity.
R / can reduce ached at the foot area.
4. Avoid foods that contain nuts.
R / can prevent arthritis.
5. Teach the foot by not using footwear in the morning.

2. Acute Pain: (headaches / dizziness) related to fatigue.

Goal:
headaches / dizziness is reduced

Expected outcomes are:
  • Headaches / dizziness is reduced.
  • Not nervous.
  • Not pale.
  • Can not sleep.
  • No pacing.
Intervention:
1. Explain to the client about the cause of headaches / dizziness.
R /: to understand the cause of headaches / dizziness.
2. Provide a description of the kx about the side effects of taking medications too often.
R /: understand the side effects of medication.
3. Give nonfarmakologi action to eliminate the headaches, such as a cold compress on the forehead, back and neck massage, a quiet, dim the lights, relaxation techniques.
R /: relieve headaches.
4. Give analgesics as indicated.
R /: to help relieve headaches.

3. Activity intolerance related to imbalance of O2 supply: weakness.

Goal:
  • Able to do the activity.
  • Not tired.
  • Do not bother.
  • Vital signs are normal.
Intervention:
1. Review of daily activities.
2. Teach for leg exercises every hour / ROM.
3. Teach ± ​​sit 3-5 minutes before standing and walking.
4. Increased frequency of activity and distance gradually.

5. Risk for infection related to the state of nutrition: state of immunity.

Goal:
  • There was no infection.
  • Normal body temperature (36-370C).
  • There is no redness, irritation around the wound.
  • Normal leucocytes (10,000 m 4500-I)
Intervention:
1. Teach to minimize contact and pathogens.
2. Explain the need to maintain hygiene
(For example: Shower every day, oral care).
3. Examine the mouth and throat with signs of infection.
4. Teach drinking 200cc/hari.
5. Strive to improve nutrition, diit enough.
6. Provision of adequate vitamins and minerals.