Nursing Care Plan for Hypoglycemia: Activity Intolerance

Nursing Care Plan for Hypoglycemia: Activity Intolerance

Nursing Care Plan for Hypoglycemia - Activity Intolerance   October 16, 2015

Nursing Care Plan for Hypoglycemia

Activity Intolerance related to imbalance of oxygen supply and demand, weakness.

Defining characteristics:

• Fatigue and weakness.
• The response to activity indicates abnormal pulse and blood pressure.
• Changes in ECG showed arrhythmia / dysrhythmia.
• Dyspnea and discomfort.
• Agitated.

Goal: The client is able to achieve: activity tolerance,

with expected outcomes:

Activity Tolerance:

• Oxygen saturation within normal limits when activity.
• HR in the normal range when the activity.
• Respiration in the normal range when the activity.
• Systolic blood pressure in the normal range when the activity.
• Diastolic blood pressure in the normal range when the activity.
• ECG within normal limits.
• Skin color.
• Breathing efforts when the activity.
• Walking in the room.
• Walk away.
• Climbing up the stairs.
• ADL strength.
• The ability to talk while exercising.

Interventions :

Therapeutic Activities:

• Note the frequency of heart rhythm, changes in blood pressure before, during and after activity as indicated.
• Increase rest, limit activity and provide leisure activities that are not heavy.
• Limit visitors.
• Monitor response to emotional, physical, social and spiritual.
• Describe the pattern of a gradual increase in activity.
• Help clients recognize a meaningful activity.
• Help clients know the options for activity.
• Determine the client's commitment to increase the frequency of the activity.
• Collaboration related to the physical, recreational therapy, proper supervision activity program.
• Help the client make a specific plan for the transfer of routine daily activity.
• Help the client / family know all the quality of a shortage of activity.
• Train the client / family about the role of physical, social, spiritual, sense activity in health care.
• Help the client / family environment with a desire to adjust the activity.
• Provide activities that increase attention in a certain period.
• Facilitation replacement activity when the client has passed the deadline, energy and movement.
• Provide an environment that is not harmful to walk as indicated.
• Provide positive reinforcement for participation in the activity.
• Help the client generates its own motivation.
• Monitor the emotional, physical, social, and spiritual activities.
• Help the client / family getting monitor progress toward achieving the goal.

Energy Management :

• Observation of the client restrictions in activity.
• Encourage to express feelings towards limitations.
• Assess the factors that cause fatigue.
• Monitor nutrition and adequate sources of energy.
• Monitor the client for physical fatigue and emotional excess.
• Monitor the cardiovascular response to activity.
• Monitor patterns of sleep and duration of sleep / rest.

Dysrhythmia Management :

• Knowing for certain clients and families who have a history of heart.
• Monitor and check oxygenation deficiency, acid-base balance, electrolytes.
• Record ECG.
• Advise the client to break every attack.
• Record the frequency and duration of the attack.
• Monitor hemodynamic status.

Activity Intolerance - Hypertensive Heart Disease Care Plan

Activity Intolerance - Hypertensive Heart Disease Care Plan

Nursing Care Plan   November 07, 2013

Hypertensive heart disease refers to heart conditions caused by high blood pressure.

These problems include:

• Coronary artery disease and angina
• Heart failure
• Thickening of the heart muscle (called hypertrophy)

Hypertensive heart disease includes, among other conditions, heart failure, thickening of the heart muscle, and coronary artery disease. Coronary heart disease, for example, occurs when high blood pressure causes narrowing of the blood vessels that supply your heart with blood and oxygen.

Nursing Care Plan for Hypertensive Heart Disease

Nursing Diagnosis : Activity Intolerance related to general weakness, imbalance between supply and oxygen demand.

Goal:

• Clients are able to do activities that are tolerated

Outcomes:

• Clients participate in activities desired / required.
• Reported an increase in tolerance activity can be measured.
• Showed a decrease in physiological signs of intolerance.

Interventions and Rationale:

Interventions:
1. Assess the client's response to the activity, the attention of more than 20 pulse / min above the break frequency; significant increase in BP during / after activity, dyspnea, chest pain; excessive fatigue and weakness; diaphoresis; dizziness or fainting.

2. Instruct patients about energy saving techniques, eg, using a chair in the shower, sitting as combing hair or brushing teeth, doing activities slowly.

3. Encourage daily activity / self-care gradually if tolerated. Provide assistance as needed.

Rationale:

1. Mentioned parameters help in assessing physiological responses to stress and activity when there is an indicator of excess work-related activity levels.

2. Energy saving techniques reduce energy reduction also helps balance between supply and oxygen demand.

3. Progress activity increased gradually to prevent sudden cardiac work. Provide only limited assistance needs will encourage independence in their daily activities.

Nursing Care Plan for Congestive Heart Failure - CHF

Nursing Diagnosis for Ischemic Heart Disease

Nursing Interventions for Ischemic Heart Disease - Acute Pain

Nursing Care Plan for Nausea and Vomiting

Nursing Care Plan for Nausea and Vomiting

Vomiting   October 30, 2013

Nausea

Nausea is the sensation (feeling) issued a strong food or want to vomit. Usually accompanied by autonomic signs such as hypersalivation, diaphoresis, tachycardia, pallor, and tachypnea, nausea closely related to anorexia. Nausea caused by distention or irritation in any part of the gastrointestinal tract, but can also be stimulated by higher brain centers.

Nausea is a common symptom of digestive disorders, but may also occur in fluid and electrolyte imbalance, infection, metabolic disorders, endocrine, and cardiac maze. Can also be as a result of drug therapy, surgery, and radiation.

Nausea is also common in the first trimester of pregnancy, nausea can arise from intense pain, anxiety, alcohol poisoning, excessive food or digest food or drinks that do not taste good.


Definition of "Vomit" is a discharge of most or all of the stomach contents food into the stomach occurs after a while, accompanied by contraction of the stomach and abdomen. (Vivian Nanny Lia Dewi, 2010)

In a simple sense of Vomiting is spending the stomach contents through the mouth. Another understanding of the vomiting is a discharge of most or all of the stomach contents food into the stomach occurs after a while, with stomach and abdominal contractions. In the first few hours after birth, the baby may experience vomiting mucus, sometimes with a little blood. Vomiting is not uncommon to settle after breast feeding or food, the situation is probably due to irritation of the gastric mucosa by a number of objects that are ingested during childbirth.

Many causes that can lead to vomiting, namely:

• Virus infection
• Stress
• Gestation
• Drug
• Myocardial infarction
• Uremia
• Other conditions

Therapeutic Intervention

Nausea and vomiting are very few require intervention. However, if left unchecked will lead to dehydration and electrolyte imbalance. Loss of hydrochloric acid from the stomach can cause metabolic alkalosis. Vomiting black, like coffee, showed vomit mixed with blood. Protection of the airway during vomiting are the most important measures to prevent aspiration. Increased risk of aspiration in patients with loss of consciousness, the elderly, and the failure of reflexes. Place the patient in a comfortable position so that vomit out. Beating back while vomiting can lead to aspiration.


Nursing Process in Patients with Nausea and Vomiting

Assessment / data collection

1. Episodes of nausea and vomiting
2. Medical condition
3. Drugs consumed
4. Treatment is being done

Early signs of fluid loss:

1. Weakness
2. Headache
3. Not be able to concentrate
4. Postural hypotension

Further signs of fluid loss:

1. Confused
2. Oliguria
3. Skin cool and moist
4. Chest and abdominal pain

Nursing Diagnosis, Planning, and Implementation

1 . Nausea related to various causes

The desired result :

• Patients expressed no nausea and vomiting .
• Odor-free environment , clean so it does not cause nausea .

Interventions :

1. Give anti- emetic .
2. Oral care , to reduce emesis and increased comfort .
3. Explained to the patient to avoid foods that cause or may cause vomiting .

2 . Risk for aspiration related to decreased reflexes or awareness

The desired result :

• Airway and lung sounds clean patient

Iintervention :

1. Assess whether the patient is in the risk for aspiration .
2. Place the patient in a position to prevent aspiration .

3 . Deficient Fluid Volume

The desired result :

• Patient's vital signs within normal limits .

Interventions :

1. Monitor for signs of hypovolemia to prevent any complications that may occur .
2. Measure body weight each day .
3. Monitor intake output , and vital signs , and vital signs , blood pressure ortohstatik .
4. Give fluids by IV .
5. Discharge monitoring during treatment to prevent deficit and excess fluid .

Evaluation

Patients showed no nausea, lung sounds clean and normal vital signs .

Imbalanced Nutrition : less than body requirements related to nausea and vomiting

Risk for Fluid Volume Deficit related to Vomiting

Appendicitis Pre- and Post-Operative Care Plan

Appendicitis Pre- and Post-Operative Care Plan

Surgical Nursing   October 27, 2013

Appendicitis Pre Operative Care:

• Sonde installation to decompress the stomach.
• Catheters to control urine production.
• Rehydration.
• Antibiotic with broad spectrum and is given intravenously.
• Fever-reducing medicines.
• If fever, should be reduced before anesthesia.

Appendicitis Operative Care :

• Appendectomy
• Appendix removed, if the appendix is perforated freely, then the abdomen was washed with physiological saline and antibiotics.
• Appendix abscess treated with IV antibiotics, its mass may shrink, or abscess may require drainage within a few days.
• Appendectomy done if the abscess performed elective surgery after 6 weeks to 3 months.

Appendicitis Post Operative Care:

• Observation of vital signs.
• Lift the stomach sonde when patients have realized that aspiration of gastric fluid can be prevented.
• Put the patient in a semi-Fowler position.
• Patients are said to be good when it is in 12 hours without any disturbance, during fasting.
• When the action is bigger operation, for example the perforation, fasting continued until bowel function returned to normal.
• Give drink from 15 ml / hour, for 4-5 hours, then raised it to 30 ml / hour. The next day give food strain, and the next day be given soft foods.
• One day after surgery the patient is advised to sit upright in bed for 2 × 30 min.
• On the second day the patient can stand and sit outside the room.
• Day 7 stitches can be removed and the patient allowed to go home.

In the appendix to the state of the masses who are still active inflammatory process that is characterized by:

• General state of the client it still looks sick, the body temperature is still high.
• Local examination of the right lower quadrant of the abdomen are still clear signs of peritonitis.
• Laboratory there are leukocytosis and the counts are shifting to the left.

Surgery should be performed as soon as the client is prepared, because it feared would happen appendix abscess and generalized peritonitis. Preparation and surgery should be done as well as possible given the complications of wound infection is higher than surgery in simple appendicitis without perforation.

On the state of the appendix mass with inflammatory process has subsided characterized by:

• General condition has improved with no visible pain, body temperature is not high anymore.
• Local inspection abdomen there are no signs of peritonitis and only clear and palpable mass with mild tenderness.
• Laboratory leukocyte count and differential count normal.

Actions taken should be conservative with antibiotics and bed rest. Surgery if the bleeding was more difficult and more, especially when mass appendix has formed more than a week since the attacks of abdominal pain. Surgery is carried out immediately if the treatment occurs abscess with or without generalized peritonitis.

Impaired Skin Integrity related to Cellulitis Care Plan

Impaired Skin Integrity related to Cellulitis Care Plan

Nursing Care Plan   October 27, 2013

Cellulitis is a skin infection that is caused by bacteria. The bacteria called Staphylococcus aureus and Group A Streptococcus are usually responsible for this kind of infection. Streptococci and Staphylococci can enter the skin to cause cellulitis infection through scrapes, cuts, wounds, blisters, insect bites and ulcers and find their way into the dermal and subcutaneous layers of the skin. Different cellulitis infections are facial cellulitis, breast cellulitis, orbital (eye) cellulitis, periorbital (eyelid) cellulitis, hand or arm cellulitis, perianal cellulitis and lower leg or foot cellulitis.

The main symptoms are skin redness or inflammation that spreads in size as the infection spreads , tight, glossy, stretched occurrence of the skin , tenderness of the area , skin injury or rash, sudden onset ,warmth over the redskin,fever .there are some other signs of infection includes chills, shaking, fatigue, warm skin, sweating, muscle aches, myalgias. Some of the additional symptoms that may be related with this disease are nausea, vomiting and hair loss at the site of infection.


Nursing Diagnosis and Interventions for Cellulitis

Impaired Skin Integrity related to changes in turgor

Goal: Demonstrate tissue regeneration.

Outcomes:

• Lesions began to recover and the free area of the infection,
• Clean skin,
• Dry and surrounding area free from edema,
• Normal temperature.

Nursing Intervention:

1. Assess the damage, size, color depth of the liquid.
R /: proper assessment of the wound and the healing process will assist in determining further action.

2. Maintain bed rest with an increase in limb and mobilization.
R /: Circulation that can smoothly accelerate the wound healing process.

3. Maintain aseptic technique.
R /: to accelerate the wound healing process.

4. Use the compress and bandage.
R /: Compress and dressing could reduce contamination from outside.

5. Monitor the temperature of the report, report your doctor if there is improvement.
R /: Early indications for infectious complications.

Nursing Care Plan for Acute Tonsillitis

Nursing Care Plan for Acute Tonsillitis

Nursing Care Plan   October 20, 2013

Tonsillitis is an inflammation of the tonsils. according to the stage, tonsillitis is divided into three stages, namely:

1. Acute tonsillitis
2. Membranous tonsillitis
3. Chronic tonsillitis

Acute Tonsillitis
Acute definition is an inflammation of the tonsils and sudden in onset.

Etiology

1. Group A Beta-Hemolytic Streptococcal.
2. Pneumococcus.
3. Staphylococcus.
4. Haemophilus influenzae.

Pathophysiology

1. Inflammation of the tonsils caused by a virus.
2. Resulted in the formation of exudate.
3. Cellulitis tonsils and surrounding areas.
4. Peritonsilar abscess formation.
5. Tissue necrosis.

Symptoms

1. Sore throat and dysphagia.
2. Patients do not want to eat or drink.
3. Malaise.
4. Fever.
5. Breath odor.
6. Otitis media is one of the originators.

Management

1. Bed rest.
2. Provision of adequate fluids and light diet.
3. Giving medications (analgesics and antibiotics).
4. If there is no progress then the alternative actions that can be done is surgery.

Preparation operations may be undertaken

1. Laboratory tests (hemoglobin, leukocytes, bleeding time).
2. Give an explanation to the client, treatment and care after surgery.
3. Fasting 6-8 hours before surgery.
4. Give antibiotics as prophylaxis.
5. Give premedication ½ hours before surgery.

Assessment

1. Medical history factors associated with the occurrence of tonsillitis supporters , as well as bio - psycho - socio - spiritual.

2. Circulatory
Palpitations, headache during position changes, decreased blood pressure, bradycardia, body felt cold, pale extremities appear.

3. Elimination
Changes in the pattern of elimination ( urinary incontinence ), abdominal distension, bowel sounds disappearance.

4. Activity / rest
There is a decrease in activity due to body weakness, loss of sensation or parese / plegia , tiredness, difficulty in recuperating from muscle cramps or spasms and pain. The reduced level of consciousness, decreased muscle strength, general body weakness.

5. Nutrition and fluids
Anorexia, nausea and vomiting due to increased ICP ( intracranial pressure ), impaired swallowing, and loss of sensation on the tongue.

6. Nervous system
Dizziness / syncope, headache, decreased visual field wider / blurred vision, decreased touch sensation, especially in the area of ​​the face and extremities. Comatose mental status, weakness in the extremities, muscle paralise face, aphasia, dilated pupils, decreased hearing.

7. Comfort
Tense facial expressions, headache, restlessness.

8. Breathing
Shortened breath, inability to breathe, apnea, apnea onset period in breathing patterns.

9. Security
Fluctuations of temperature in the room.

10. Psychological
Denial, disbelief, anguish, fear, anxiety.