Basic Concept of Nursing Care Plan for Stroke

Assessment is an early stage and the foundation of the nursing process to identify client problems, in order to give direction to nursing actions. Assessment phase consists of three activities: data collection, data classification and formulation of nursing diagnoses. (Lismidar, 1990)

Data Collection

Data collection is to collect information about the overall health status of the client's physical, psychological, social, cultural, spiritual, cognitive, developmental level, economic status, ability to function and lifestyle of patients. (Marilynn E. Doenges et al, 1998)

a) The identity of the client
Includes name, age (most often in old age), sex, education, address, occupation, religion, ethnicity, date and time of hospital admission, registration number, medical diagnosis.
b) The main complaint
Limb weakness typically found next to the body, speech pelo, and can not communicate. (Jusuf Misbach, 1999)
c) History of present illness
Hemorrhagic stroke often take place very suddenly, when the client is doing the activity. Usually occurs headache, nausea, vomiting and even seizures to unconsciousness, paralysis symptoms besides half body or other brain dysfunction. (Siti Rochani, 2000)
d) History of previous illness
A history of hypertension, diabetes mellitus, heart disease, anemia, history of head trauma, a long oral contraceptives, use of anti-coagulant drugs, aspirin, vasodilators, addictive drugs, obesity. (Donna D. Ignativicius, 1995)
e) A family history of disease
There is usually a family history of hypertension or diabetes mellitus. (Hendro Susilo, 2000)
f) Psychosocial History
Stroke is a disease that is very expensive. The cost for testing, treatment and care of the family finances that can disrupt these cost factors can affect the stability of the emotions and thoughts of clients and families.


The Patterns of Health Functions

1) Pattern perception of healthy living and governance
There is usually a history of smoking, alcohol use, use of oral contraceptives.
2) The pattern of nutrition and metabolism
Complaints difficulty swallowing, loss of appetite, nausea and vomiting in the acute phase.
3) The pattern of elimination
It usually occurs in the urinary incontinence and bowel habit constipation usually occurs due to decreased intestinal peristalsis.
4) The pattern of activity and exercise
There is the difficulty of the move as weakness, sensory loss or paralise / hemiplegia, tiredness.
5) The pattern of sleep and rest
Usually clients are having difficulties to rest because of muscle spasms / muscle pain.
6) The pattern of relationships and roles
A change in the relationship and role as client has difficulty communicating due to impaired speech.
7) The pattern of perception and self-concept
Clients feel helpless, hopeless, irritable, uncooperative.
8) The pattern of sensory and cognitive
At the client's pattern of sensory impaired vision / blurring sight, touch / touch down on the face and extremity pain. On the pattern of cognitive decline typically memory and thought processes.
9) Patterns of sexual reproduction
It usually occurs due to decreased sexual desire of some of the treatment of stroke, such as anti-seizure drugs, anti-hypertensive, histamine antagonists.
10) The pattern of response to stress
Clients often find it difficult to solve due to the disruption of thinking and difficulty communicating.
11) The pattern of values ​​and beliefs
Clients rarely practicing because of unstable behavior, weakness / paralysis on one side of the body.

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Nursing Care Plan for Brain Tumor

Definition

Brain tumors are lesions because there is pressure both benign and malignant space that grows in the brain, meninges and the skull.

Etiology

• History of head trauma
• Genetic factors
• Exposure to chemicals that are carsinogenik
• Certain viruses

Pathophysiology

Brain tumors occur because of proliferation or growth of abnormal cells very rapidly in areas central nervous system (CNS). These cells will continue to evolve urge healthy brain tissue around it, causing neurological disturbances (focal disruption caused by the tumor and increased intracranial pressure).

Clinical manifestations
a. Headache
The pain is deep, constant, dull and sometimes it is terrific. Usually most severe in the morning and aggravated during activity, which usually causes an increase in intra-cranial pressure is coughing, bending and straining.

b. Nausea and vomiting
As a result of stimulation of the medulla oblongata

c. Papilledema
Venous stasis causing swelling of optic nerve papilla.

Nursing Care Plan for Brain Tumor

Nursing Assessment

a. Identification of risk factors for exposure to radiation or chemicals that are carcinogenic.

b. Identify the signs and symptoms are: headache, vomiting, and decreased vision or double vision.

c. Identify any changes in client behavior.

d. Observation of hemiparese or hemiplegia.

e. Changes in sensation: hyperesthesia, paresthesia.

f. Observation of sensory changes: asteregnosis (not able to feel the sharp edges), agnosia (not able to recognize objects in general), apraxia (not being able to use the tool properly), agraphia (can not write).

g. Observation of vital signs and level of consciousness.

h. Observation circumstances fluid and electrolyte balance.

i. Psychosocial: personality and behavioral changes, difficulty making decisions, anxiety and fear of hospitalization, diagnostic tests and surgical procedures, a change in the role.


Nursing Diagnosis for Brain Tumor

1. Ineffective tissue perfusion related to circulatory damage caused by a tumor suppression.

2. Pain (Acute / Chronic) related to increased intracranial pressure.

3. Knowledge Deficit: the condition and treatment needs related to the inability to know the information.

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Risk for Injury Nursing Care Plan Preeclampsia

Nursing Care Plan Preeclampsia

There are certain conditions that arise during the pregnancy that can lead to a high incidence of birth injuries. One of those conditions is preeclampsia. It is important that the mum is given the right treatment before the birth so that the risk of injury is minimized in the majority of cases. It is said that about seven out of one thousand babies suffer birth injuries.

Preeclampsia signs can persist for as long as 3 months after birth but usually disappear entirely in most women.

If preeclampsia is left untreated the blood pressure can become so high that the woman is at increased risk of seizures. Symptoms of preeclampsia are right upper abdominal pain, headache, disturbance in vision and alteration in mental state. Permanent injury to the brain, liver and kidneys have been reported in uncontrolled preeclampsia. Reduced placental blood flow leads to less oxygen and nutrient supply to the baby. Fetal growth slows and a preterm delivery is associated with breathing difficulties for the baby when it is born.

Risk Factors For Preeclampsia

• Previous kidney disease.
• Teenage mothers and women over 35 year of age.
• Twins or more.
• History of Lupus.
• Assisted reproduction.
• Barrier methods of contraception.
• First pregnancy or first pregnancy with a new partner.
• History of diabetes.
• Presence of essential hypertension (high blood pressure).

Nursing Diagnosis for Preeclampsia : Risk for Injury: the fetus is related to an inadequate blood perfusion to the plasma

Goal: Injury did not occur in the fetus

Nursing Interventions for Preeclampsia:

1. Instruct the patient to Rest
Rational: By resting the client, is expected to decrease the body's metabolism and blood circulation to the placenta to be more adequate to the need of oxygen to the fetus can be met.

2. Encourage clients to sleep on their left
Rationale: With the left side sleeping is expected vena cava on the right is not depressed by the enlarged uterus so that the flow palasenta darh to be smooth.

3. Monitor blood pressure
Rationale: The client can monitor blood pressure condition known as placental blood flow to high blood pressure, blood flow to the placenta is reduced so that the supply of oxygen to the fetus is reduced.

4. Monitor the client's heart sounds
Rational: By monitoring the fetal heart sounds can be known to the state of the fetal heart is weak or declining indicating reduced supply of oxygen to the placenta so that action can be planned in advance.

5. Give anti-hypertensive drugs will lower the tone of the arteries and cause a decrease in cardiac afterload by vasodilatation of blood vessels so that blood pressure down.
Rationale: By decreasing blood pressure so that blood flow to the placenta becomes more adequate.

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Nursing Care Plan for Elderly

Assessment - 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.

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2 Nursing Care Plan for Rheumatic Heart Disease - Assessment, Diagnosis and Interventions

Nursing assessment is done in providing nursing care in rheumatic heart disease beginning to collect data on the following matters:

• About heart function.
• Nutritional status of patients.
• Tolerance to the activities and attitudes of patients toward limiting the activities undertaken.
• Disturbances in sleep patterns.
• Level of discomfort felt by rheumatic fever patients.
• Ability of the patient in terms of troubleshooting.
• Knowledge of patients and families will be suffered by rheumatic heart disease.

Assessment of the above are generally aware of what is known by the patient and the family of rheumatic heart disease. Now the next step in the assessment in terms of nursing as one of the nursing process. Next examined the nursing care in rheumatic heart disease are:

• History of rheumatic heart disease.
• Monitor cardiac complications in the event.
• Auscultation of heart sounds, usually typical in patients with rheumatic heart was weakened heart sounds with the rhythm of galloping diastole.
• Assessment of the patient's vital signs.
• Assessment of pain.
• Assessment of the presence of markers of inflammation in the joints.
• Assessment of the presence of lesions on the skin.

Nursing Care Plan for Rheumatic Heart Disease

Next is the nursing diagnosis of rheumatic heart disease. Some nursing diagnoses that may arise in providing nursing care in rheumatic heart disease, among which are:

1. Decreased cardiac output related to valvular stenosis

Goals to be achieved is to increase cardiac output.

Expected outcomes are:

• Patients showed reduced levels of dyspnoe experienced.
• Patients participating in participating in the activity and demonstrate increased tolerance.

Nursing interventions:

• Monitor vital signs such as: blood pressure, apical pulse and peripheral pulse.
• Monitor cardiac rhythm and frequency.
• Semifowler bed rest in a position that is 45 degrees.
• Encourage the patient to stress management techniques (quiet environment, meditation).
• Bantu patient activity as indicated when the patient is able.
• Medical collaboration in terms of oxygen delivery and therapy.

2. Activity intolerance related to decreased cardiac output, oxygen supply and demand imbalance.

Goals to be achieved is an optimal patient can tolerate the activity does.

Expected outcomes are:

• Verbal response to reduced fatigue
• Conducting activities within the limits of his ability (pulse activity should not be more than 90X/mnt, no chest pain).

Nursing interventions:

• Energy saving during the acute patients.
• Maintain bed rest until the results of laboratory and clinical status of patients improved.
• In line with the good general condition, monitor the gradual increase in the level of activity undertaken.
• Teach to participate in activities of daily necessities.
• Create a schedule of activities and also the breaks.

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Nursing Care Plan for Cardiac Arrhythmias

Heart rhythm disorder or arrhythmia is a frequent complication in myocardial infarction. Arrhythmias or dysrhythmias is the change in frequency and heart rhythm caused by abnormal conduction of the electrolyte or automatic (Doenges, 1999).

Arrhythmias arise from changes in myocardial cell electrophysiology. Electrophysiological changes are manifest as changes in the form of an action potential is a graph recording the electrical activity of cells (Price, 1994). Heart rhythm disorders are not just limited to heart rate irregularities, but also including the rate and conduction disturbances (Hanafi, 1996).


Etiology

Etiology of cardiac arrhythmias in the outline can be caused by:

1. Inflammation of the heart, such as rheumatic fever, myocardial inflammation (myocarditis due to infection)
2. Interruption of coronary circulation (coronary atherosclerosis or coronary artery spasm), such as myocardial ischemia, myocardial infarction.
3. Because the drug (intoxication), among others, by digitalis, quinidin and anti-arrhythmia drugs other.
4. Electrolyte imbalance (hyperkalemia, hypokalemia)
5. Disorders of the autonomic nervous system settings that affect the work and the rhythm of the heart.
6. Psychoneurotic disorders and central nervous system.
7. Metabolic disorders (acidosis, alkalosis)
8. Endocrine disorders (hyperthyroidism, hypothyroidism)
9. Arrhythmia due to cardiomyopathy or heart tumor
10. Heart rhythm disturbances due to degeneration disease (fibrosis of the cardiac conduction system)

Clinical Manifestations

1. Changes in BP (hypertension or hypotension); pulse may be irregular; pulse deficit; sounds irregular heart rhythm, extra sounds, beats down; pale skin, cyanosis, sweating; edema; decreased urine output when cardiac output decreased weight.
2. Syncope, dizziness, throbbing, headache, disorientation, confusion, lethargy, pupillary changes.
3. Mild to severe chest pain, may be lost or not with anti-angina drugs, anxiety
4. Shortness of breath, cough, change in velocity / depth of breathing; additional breath sounds (crackles, wheezing) may have showed respiratory complications such as left heart failure (pulmonary edema) or pulmonary tromboembolitik phenomenon; hemoptysis.
5. Fever; skin redness (drug reactions); inflammation, erythema, edema (siperfisial thrombosis); loss of muscle tone / strength

Physical Assessment

1. Activities: general fatigue
2. Circulation: changes in BP (hypertension or hypotension); pulse may be irregular; pulse deficit; sound of irregular heart rhythm, extra sounds, beats down; skin color and moisture changes such as pallor, cyanosis, sweating; edema; decreased urine output when cardiac output decreased weight.
3. Ego Integrity : feeling nervous, feeling threatened, anxious, frightened, refused, angry, anxious, crying.
4. Food / fluid: loss of appetite, anorexia, food intolerance, nausea, vomiting, weight peryubahan, changes in skin moisture
5. Neuro-sensory: dizziness, throbbing, headache, disorientation, confusion, lethargy, pupillary changes.
6. Pain / discomfort: mild to severe chest pain, may be lost or not with anti-angina drugs, anxiety
7. Respiratory: chronic lung disease, shortness of breath, cough, change in velocity / depth of breathing; additional breath sounds (krekels, crackles, wheezing) may have showed respiratory complications such as left heart failure (pulmonary edema) or pulmonary tromboembolitik phenomenon; hemoptysis.
8. Security: fever; skin redness (drug reactions); inflammation, erythema, edema (siperfisial thrombosis); loss of muscle tone / strength.

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Assessment Nursing Care Plan for Chest Pain

Common signs and symptoms that accompany chest pain are:

• Heartburn
• Headache
• Pain that is projected onto the arm, neck, back
• Diaphoresis / sweating
• Shortness of breath
• Tachycardia
• Pale
• Difficulty sleeping (insomnia)
• Nausea, vomiting, anorexia
• Anxiety, nervous, focus on yourself
• Weakness
• The face tense, m erintih, crying
• Changes in consciousness

Primary Assessment - Nursing Care Plan for Chest Pain

a. Airway
- How airway clearance?
- Is there any obstruction / accumulation of secretions in the airway?
- How to breath sounds, is there any additional breath sounds?

b. Breathing
- What is the pattern of breath? frequency? the depth and rhythm?
- What is the use of auxiliary respiratory muscles?
- Are there any additional breath sounds?

c. Circulation
- How does the peripheral arteries and carotid arteries? quality (content and voltage)
- How capillary refill, what there is akral cold, cyanosis or oliguria?
- Is there a decrease in consciousness?
- How vital signs? blood pressure, temperature, pulse, respiration?


2. Secondary Assessment - Nursing Care Plan for Chest Pain

Important things that need to be studied further in chest pain (coronary):

a. location of pain
Where to start, propagation (coronary chest pain: from the sternal border radiating to the neck, chin or shoulder to the left arm of the ulna)

b. The nature of pain
Feeling of fullness, heaviness such as seizures, squeezing, stabbing, choking / burning, etc..

c. Characteristics of pain
Degree of pain, duration, how many times arise in a given time period.

d. chronological pain
Beginning there is pain and progress in sequence

e. Circumstances at the time of the attack
Whether arising in times / circumstances

f. Factors that reinforce / relieve pain such as attitude / posture, movement, pressure, etc..

g. Other symptoms that may be present whether or not the relationship with chest pain.

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10 Nursing Care Plan for Liver Cirrhosis : Diagnosis

Nursing Care Plan for Liver Cirrhosis

Liver cirrhosis is a degenerative inflammatory disease that results in hardening and scarring of liver cells. The loss of liver cells interferes with the organ's ability to process nutrients, hormones, and drugs and slows the production of protein other important substances manufactured in the liver. Liver becomes unable to function properly due to the scarred tissue, which prevents the normal passage of blood through the liver.

Some main physical indications of liver cirrhosis are jaundice and yellow discoloration of the skin. However, patients do display some other symptoms such as itching, which is medically termed as pruitus and fatigue. There are many reasons behind liver cirrhosis condition; some of the main ones are extreme alcohol intake, hepatitis B and C infections, and fatty liver, exposure to insecticides.

The most common symptoms are loss of appetite, loss of body weight, nausea, pain in abdominal area in the location of liver, weakness in body and itchy skin. Severe conditions include yellow discoloration of skin, cramps, mental imbalance and confusion and difficulty in absorption of alcohol and drugs.


10 Nursing Diagnosis for Liver Cirrhosis

1. Imbalanced Nutrition Less Than Body Requirements related to anorexia.

2. Activity Intolerance related to muscle weakness.

3. Fluid and electrolyte imbalances related to portal hypertension.

4. Ineffective Tissue Perfusion related to hematemesis and melena.

5. Anxiety related to hematemesis and melena.

6. Ineffective Breathing Pattern related to decreased lung expansion.

7. Impaired Verbal Communication related to neurological disturbances talking.

8. Risk for injury related to uncontrolled movements.

9. Impaire Physical Mobility related to the effect of muscle stiffness.

10. Self-care deficit related to a state of coma.

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3 Nursing Care Plan Diabetes Mellitus - Diagnosis, Interventions and Rational

Nursing Diagnosis for Diabetes Mellitus
1. Nursing Diagnosis : Fluid Volume Deficit related to osmotic diuresis.

Goal:
Demonstrate adequate hydration evidenced by stable vital signs, palpable peripheral pulse, skin turgor and capillary refill well, individually appropriate urinary output, and electrolyte levels within normal limits.

Nursing Intervention:
1.) Monitor vital signs.
Rational: hypovolemia can be manifested by hypotension and tachycardia.
2.) Assess peripheral pulses, capillary refill, skin turgor, and mucous membranes.
Rational: This is an indicator of the level of dehydration, or an adequate circulating volume.
3.) Monitor input and output, record the specific gravity of urine.
Rational: To provide estimates of the need for fluid replacement, renal function, and effectiveness of the therapy given.
4.) Measure weight every day.
Rational: To provide the best assessment of fluid status of ongoing and further to provide a replacement fluid.
5.) Provide fluid therapy as indicated.
Rational: The type and amount of liquid depends on the degree of lack of fluids and the response of individual patients.

2. Nursing Diagnosis : Imbalanced Nutrition Less than Body Requirments related to insufficiency of insulin, decreased oral input.

Goal:
Digest the amount of calories / nutrients right
Shows the energy level is usually
Stable or increasing weight.

Nursing Intervention:
1.) Determine the patient's diet and eating patterns and compared with food that can be spent by the patient.
Rationale: Identify deficiencies and deviations from the therapeutic needs.
2.) Weigh weight per day or as indicated.
Rational: Assessing an adequate food intake (including absorption and utilization).
3.) Identification of preferred food / desired include the needs of ethnic / cultural.
Rational: If the patient's food preferences can be included in meal planning, this cooperation can be pursued after discharge.
4.) Involve patients in planning the family meal as indicated.
Rationale: Increase the sense of involvement; provide information on the family to understand the patient's nutrition.
5.) Give regular insulin treatment as indicated.
Rational: regular insulin has a rapid onset and quickly and therefore can help move glucose into cells.

c. Nursing Diagnosis : Risk for Infection related to hyperglikemia.

Goal:
Identify interventions to prevent / reduce the risk of infection.
Demonstrate techniques, lifestyle changes to prevent infection.

Nursing Intervention:
1). Observed signs of infection and inflammation.
Rationale: Patients may be entered with an infection that usually has sparked a state of ketoacidosis or may have nosocomial infections.
2). Improve efforts to prevention by good hand washing for all people in contact with patients including the patients themselves.
Rationale: Prevents cross infection.
3). Maintain aseptic technique in invasive procedures.
Rational: high glucose levels in blood would be the best medium for the growth of germs.
4). Give your skin with regular care and earnest.
Rational: the peripheral circulation may be disturbed that puts patients at increased risk of damage to the skin / skin irritation and infection.
5). Make changes to the position, effective coughing and encourage deep breathing.
Rational: memventilasi Assist in all areas and mobilize pulmonary secretions.


Healthy Diet for Diabetes Mellitus
Nursing Diagnosis and Nursing Intervention for Diabetes Mellitus
Nursing Care Plan for Diabetes Mellitus
12 Nursing Diagnosis for Diabetes Mellitus
Nursing Care Plan for Diabetes Mellitus
Nursing Intervention for Diabetes Mellitus - Deficient Fluid volume

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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 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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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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