Encephalitis Assessment and Nursing Diagnosis

Encephalitis Assessment and Nursing Diagnosis

Nursing Diagnosis and Interventions   October 06, 2015

Encephalitis is an infection of the central nervous system caused by viruses or other microorganisms, which cause strong lymphocytic infiltration in brain tissue and leptomeninges cause cerebral edema, brain ganglion cell degeneration and destruction of nerve cells diffusion (Anania, 2008). Encephalitis is an inflammation of the brain tissue that can be caused by bacteria, worms, protozoa, fungi, rickets, or viruses (Mansjoer, 2000)

Although the cause is different, the clinical symptoms of encephalitis is more or less the same and distinctive, so that it can be used as diagnostic criteria. Generally, the symptoms include fever, convulsions and decreased consciousness. (Mansjoer, 2000).

Signs and symptoms of encephalitis as follows:

1. Sudden temperature rises, often found hyperpyrexia.
2. Consciousness quickly dropped.
3. gag.
4. Seizures, which can be general, focal or twitching only.
5. Other cerebral symptoms, which may occur individually or together, eg paresis or paralysis, aphasia, and so on.

Assessment

Data that needs to be examined include (Doenges, 1999):

1. Biodata.
Biodata is the identity of the clients includes: name, age, gender, religion, ethnicity, address, date of hospital admission, registration number, date of assessment and medical diagnostics. This identity is used to differentiate clients from one another.

2. Main complaint.
The main complaint is the need to encourage clients to enter the hospital. The main complaints in patients with encephalitis include headaches, neck stiffness, impaired consciousness, fever and seizures.

3. History of present illness.
A history of current clients which include complaints, the nature and great complaints, start or recurrence of disease ever experienced before. Usually the prodromal period lasts between 1-4 days, characterized by fever, headache, dizziness, vomiting, sore throat, malaise, pain in the extremities and pale. Followed by signs of encephalitis that the severity depends on the distribution and extent of the lesion in neurons. The symptoms such as anxiety, irritable, screaning attack, behavioral changes, impaired consciousness and convulsions sometimes with focal neurological signs such as aphasia, hemiparesis, hemiplegia, ataxia and paralysis of the nerves of the brain.

4. History of pregnancy and birth.
In this case studied, among others; a history of prenatal, natal and post natal. In prenatal history should note any disease ever suffered by the mother primarily infectious diseases. History of childbirth need to know whether the baby is born in the gestational age at term or not, because it affects the immune system against the disease in children. The trauma of childbirth also affect the incidence of diseases for example; amniotic fluid aspiration in children. History of post childbirth is necessary to know the state of the child after birth. Example: low birth weight, and Apgar score.

5. P6. revious medical history.
Contact or relationship with meningitis cases will increase the likelihood of inflammation or infection of the brain tissue. Immunizations need to be studied to determine how the child's immune system. Allergies in children need to know to be avoided because it may make things worse.

6. Family health history.
Is a picture of the health of the family, whether there is a relationship with the illness. In this situation the health status of families need to know, if there are family members who suffer from infectious diseases in connection with the disease experienced by the client (Soemarno marram, 1983).

7. Social history.
Environment and the child's family is very supportive to the growth and development of children. Traveling clinic of the disease so disturbing mental status, behavior and personality. Nurse charged assess the status of the client or family in order to prioritize the issue in treatment.

8. Basic Needs (daily activities).
In patients with encephalitis often disruption of daily habits, among others: the fulfillment of nutritional disorders because of nausea, vomiting, hypermetabolic due to infectious processes, and increased intracranial pressure. Rest patterns in patients with frequent seizures, it greatly affects the patient. Pattern personal hygiene should be practiced on the bed because the patient is weak or unconscious, and is likely to depend on others, play behavior is unknown if any changes need to know as a result of hospitalization in children.


Nursing Diagnosis for Encephalitis

1. Hyperthermia r / t the disease: infection.
2. Nausea r / t increased intracranial pressure, inflammation of the brain.
3. Disturbed Sensory Perception (type: visual, auditory, kinesthetic, tactile, olfactory) r / t biochemical imbalances.
4. Risk for trauma r / t reduction in muscle coordination.

Nursing Diagnosis and Interventions for Cirrhosis of the Liver

Nursing Diagnosis and Interventions for Cirrhosis of the Liver

Nursing Diagnosis and Interventions for Cirrhosis of the Liver   September 26, 2015

Nursing Diagnosis 1.

Self-Care Deficit related to fatigue and the presence of ascites.

Goal: The client is able to care for themselves.
Expected outcomes: The client is able to show self-care activities.

Interventions :

1. Give the rest during the acute phase.
Rationale: Increased rest and tranquility providing the energy that is used for healing.

2. Give light activity during bed rest.
Rationale: Bed rest time, can reduce the ability, this is precisely the case due to the limited activities that disrupt the rest period.

3. If the client is tired, limit visits of family or friends.
Rationale: Increase rest and tranquility providing the energy that is used for healing.


Nursing Diagnosis 2.

Imbalanced Nutrition Less Than Body Requirements related to anorexia.

Goal: Nutrition clients are met.
Expected outcomes: The client is able to exhibit a lifestyle to improve or maintain an appropriate body weight, showed weight gain goals with laboratory values, and freely sign of malnutrition.

Interventions:

1. Observation vital signs.
Rationale: To determine the general state of the client.

2. Monitor dietary intake, or the number of calories and provide little in the frequency often.
Rationale: Eat a lot harder when the client anorexia. Anorexia is also the worst during the day, make food intake difficult in the afternoon.

3. Provide oral care before meals.
Rationale: Eliminate sense, it can not increase the appetite.

4. Monitor blood glucose.
Rationale: hyperglycemia or hypoglycemia can occur require changes in diet or insulin administration.

5. Collaboration: Consultation with a dietitian to provide a diet in accordance with the client's needs with the input of fat and protein as tolerated.
Rationale: Allows to create a diet program for individual needs. Protein restriction is indicated in severe diseases like hepatitis.


Nursing Diagnosis 3.

Risk for Impaired tissue integrity related to bed rest, ascites and edema.

Goal: Do not damage the integrity of the skin.

Expected outcomes: Identify the risk factors and shows the behavior or technique to prevent skin damage.

Interventions:

1. Elevate the lower extremities.
Rationale: Improves venous return and decrease edema in the extremities.

2. Keep the sheets dry and free of creases.
Rational: Humidity increase pruritus and improve skin damage.

3. Cut fingernails to short, and give the gloves if desired.
Rationale: Prevent clients from injury to the skin, especially at bedtime.

4. Give the massage at bedtime.
Rational: Beneficial to improve sleep by reducing skin irritation.

12 Nursing Diagnosis for Mitral Stenosis

12 Nursing Diagnosis for Mitral Stenosis

Nursing Diagnosis and Interventions   October 14, 2013

Nursing Care Plan for Mitral Stenosis

Mitral stenosis is a narrowing of the mitral valve in the heart. This restricts the flow of blood through the valve. Back pressure which builds up behind the narrowed valve can cause various problems and symptoms. The more severe the narrowing, the more serious the problems.

Mitral stenosis (MS) is characterized by obstruction to left ventricular inflow at the level of mitral valve due to structural abnormality of the mitral valve apparatus. The most common cause of mitral stenosis is rheumatic fever.

Symptoms can include:

• Shortness of breath. This tends to occur on exercise at first, but occurs at rest if the stenosis becomes worse. This symptom is due to the congestion of blood and fluid in the lungs.
• Fainting, dizziness or tiredness. If the amount of blood getting through to the ventricle is reduced, the output of blood from the left ventricle to the body is then reduced.
• Chest pains (angina). This may develop if there is a reduced blood flow to the coronary arteries (the arteries that take blood to the heart muscle).
• Chest infections. These are common.
• Coughing up blood-stained sputum. This may occur due to the congestion of blood and fluid in the lungs.

If rheumatic fever is the cause then, typically, symptoms start between the ages of 20 and 50. (That is, 10-20 years after having have had an episode of rheumatic fever as a child.)


12 Nursing Diagnosis for Mitral Stenosis

1. Ineffective individual coping
related to :

• Situational crisis;
• Inadequate support systems;
• Ineffective coping methods.

2. Deficient Knowledge (learning needs)
related to :

• Lack of knowledge;
• Misinterpretation of information;
• Cognitive limitations;
• Deny the diagnosis.

3. Risk for Fluid Volume Excess
related to :

• The displacement of the pressure on the congestive pulmonary vein;
• Decrease in perfusion organ (kidney);
• Increased retention of sodium / water;
• Increased hydrostatic pressure, or decreased plasma protein (absorbs liquid in the interstitial area / tissue).

4. Risk for Impaired gas exchange
related to :

• Alveolar - capillary membrane changes (displacement of fluid into the interstitial area / alveoli).

5. Ineffective breathing pattern
related to:
decreased lung expansion.

6. Anxiety
related to:

• Threat of loss / death;
• Situational crisis;
• Threats to self-concept (self-image).

7. Ineffective Tissue perfusion
related to:

• Decrease in peripheral blood circulation;
• Cessation of arterial-venous flow;
• Decrease in activity.

8. Decreased cardiac output
related to:

• Obstruction of blood flow from the left atrium into the left ventricle,
• Presence of ventricular tachycardia,
• Shortening of the diastolic phase.

9. Imbalanced Nutrition: less than body requirements
related to:

• Shortness of breath.

10. Impaired Urinary Elimination
related to:

• Decreased glomerular perfusion;
• Decrease in cardiac output.

11. Risk for Fluid Volume Deficit
related to:

• Decrease in cardiac output;
• Decline in glomerular filtration.

12. Activity intolerance
related to:

• Decreased cardiac output,
• Congestive pulmunal.

Nursing Diagnosis and Interventions of Activity Intolerance in Elderly

Nursing Diagnosis and Interventions of Activity Intolerance in Elderly

Nursing Diagnosis and Interventions   October 06, 2013

Assessment

1. Physical examination:

• Musculoskeletal: decreased tone, strength, muscle size and endurance; range of motion of joints and skeletal strength.
• Cardiovascular: the formation of thrombosis, thrombophlebitis signs include: erythema, edema, tenderness and signs of positive Humans.
• Respiration: atelectasis and pneumonia symptoms, early signs include an increase in temperature and heart rate.
• Integument: ischemia injury against the first tissue is inflammatory, early changes seen on the surface of the skin as an irregular area of erythema.
• Urinary function: physical signs such as urinating a little and often, lower abdominal distension and bladder limits that can be touched.
• Gastrointestinal: constipation and faecal going small, hard and dry.
• Environment: bathroom without handles, loose rugs, lighting is not adequate, a high ladder, slippery floor and toilet seat that lowers the client mobility.

2. Assessing the skeletal body: The deformity and alignment. Abnormal bone growth due to bone tumors. Shortening of limb, amputation and body parts that are not in anatomical alignment. Abnormal angulation of the long bones or movement at a point other than the joints usually indicate the presence of fractures.

3. Assessing the spine:

• Scoliosis (curvature of the lateral deviation of the spine)
• Kyphosis (curvature of the spine increase the chest)
• Lordosis (quack, the curvature of the lumbar spine over)

4. Assessing joint system: Broad movement was evaluated both active and passive, deformity, stability, and the lumps, the joint stiffness.

5. Assessing muscle system: The ability to change the position, muscle strength and coordination, and the size of each muscle. Limb circumference to mementau or atropfi edema, muscle pain.

6. Assessing how patients walk: The irregular movements are not considered normal. If one limb shorter than the other. A variety of neurological conditions associated with abnormal gait (eg walking spastic hemiparesis way - stroke, patients go step by step - lower motor neuron disease, patients walked vibrate - Parkinson's disease).

7. Assessing the skin and the peripheral circulation: palpation of the skin can indicate a temperature hotter or colder than others and the edema. Peripheral circulation was evaluated by assessing peripheral pulses, color, temperature and capillary refill time.

8 . Assessment of functional status :

• Baths : Told independent when in client activity just need help to scrub or clean up a certain portion of the body member , said the dependent if the client requires assistance to more than one body part .
• Dress : Independent if unable to take his own clothes in a closet or drawer .
• To the toilet : Independent when the elderly can not afford to own a toilet , getting out of the toilet and hem itself . Dependent when it need a bed pan or pot .
• Transferring : Independent themselves when able to climb down from a bed or wheelchair . Dependent if always require assistance for activities above or unable to perform one or more activities of transferring .
• Continence : Independent shitting themselves when able ( urinary and defecation ) . When dependent on one or both of micturition or sefekasi require enema or catheter .
• Eating : Independent if it is able to bribe their own food , take away from the plate .

Nursing Diagnosis and Interventions of Activity Intolerance in Elderly

Nursing Diagnosis : Impaired Physical Mobility related to depression

Goal : Depression can be resolved and activities to do.

Outcomes:

Clients can perform daily activities , and depression disappeared .

Intervention :

1. The prevention of osteoporosis , either through medical intervention , nutrition , as well as lifestyle adjustments .
2. The prevention of falls in accordance with the results of the assessment of the environmental factors as well as risk factors does surgery on the risk of environmental factors .
3. Maintenance of strength and resilience of the musculoskeletal system , which includes daily exercise conditioning program both isometric and isotonic muscle contraction , strengthening and aerobic activity , nutrition and protein anabolism to increase bone formation and attitude of commitment to exercise .
4. Maintaining the flexibility of the joints involved in range of motion exercises , proper positioning and activities of daily living .
5. Maintenance of normal ventilation and hyperinflation include mobilization and eliminate secretions .
6. Maintenance of adequate circulation include supporting measures to maintain vascular tone , compression stockings to put external pressure on the limbs and adequate fluid intake to prevent dehydration effect on blood volume .
7. Maintenance of urinary and bowel function were normal relies on nutritional support and environmental structure and routines to facilitate elimination .

Imbalanced Nutrition related to Hyperemesis Gravidarum

Imbalanced Nutrition related to Hyperemesis Gravidarum

Obstetrical Nursing   September 22, 2013

Nursing Care Plan for Hyperemesis Gravidarum - Nursing Diagnosis : Imbalanced Nutrition: less than body requirements

Hyperemesis Gravidarum

Nausea and vomiting (emesis gravidarum) is a natural phenomenon and is often caught in the first trimester of pregnancy. Nausea usually occurs in the morning, but can arise at any time and at night. These symptoms occur approximately 6 weeks after the first day of the last menstrual period and lasts for approximately 10 weeks. Nausea and vomiting occur in 60-80% primi gravida and 40-60% multi gravida. One in every thousand pregnancies, these symptoms become more severe.

Nausea is largely attributable because of increased levels of estrogen and HCG (Human Chorionic Gonadrotropin) in serum. Physiological effect of the hormone increase is not clear, probably because the central nervous system or the gastric emptying of the stomach is reduced. In general, women can adapt to this situation, though symptoms of severe nausea and vomiting that can last up to 4 months. Daily work was interrupted, and the general condition became worse. This condition is called hyperemesis gravidarum. Complaints of symptoms and physiological changes determine the severity of the disease. (Prawirohardjo, 2002)

Hyperemesis gravidarum is defined as excessive vomiting or uncontrolled during pregnancy, which causes dehydration, electrolyte imbalance, or nutritional deficiencies, and weight loss. The incidence of this condition is approximately 3.5 per 1000 births. Although most cases of missing and disappeared over time, one out of every 1,000 pregnant women will undergo hospitalization. Hyperemesis gravidarum usually disappear on their own (self-limiting), but healing is slow and frequent relapses are common. The condition often occurs among primigravida women and tends to recur in subsequent pregnancies. (Lowdermilk, 2004).


Nursing Diagnosis for Hyperemesis Gravidarum : Imbalanced Nutrition: less than body requirements related to excessive frequency of nausea and vomiting.

Nursing Intervention for Hyperemesis Gravidarum

1. Limit oral intake until the vomiting stops.
R /: Maintain electrolyte fluid balance and prevent further vomiting.

2. Give anti-emetic drugs are prescribed at low doses.
R /: Preventing vomiting and maintain fluid and electrolyte balance.

3. Maintain fluid therapy is programmed.
R /: Correct the hypovolemia and electrolyte balance.

4. Record intake and output.
R /: Determining hydration fluids through vomiting and spending.

5. Anjurjan eat small meals but often.
R /: Can adequate intake of nutrients your body needs.

6. Instruct to avoid fatty foods.
R /: to stimulate nausea and vomiting.

7. Instruct the patient to eat a snack such as biscuit, bread and hot tea before getting out of bed during the day and before bed.
R /: Food distraction can reduce or avoid excessive excitatory nausea vomiting.

8. Record intake, if oral intake can not be given within a certain period.
R /: To maintain a balance of nutrients.

9. Inspection of an irritation or lesions in the mouth.
R /: To determine the integrity of the oral mucosa.

10. Assess oral hygiene and personal hygiene as well as the use of oral cleaning fluids as often as possible.
R /: To maintain the integrity of the oral mucosa.

11. Monitor hemoglobin and hematocrit.
R /: Identify the potential anemia and decreased oxygen-carrying capacity of the mother.

12. Test urine for acetone, albumin and glucose.
R /: Establish baseline data; performed routinely to detect potential high-risk situations such as the inadequate intake of carbohydrate, diabetic and hypertension due to pregnancy ketoasedosis.

13. Measure uterine enlargement.
R /: Malnutrition affects maternal fetal growth and aggravate komplemensel decrease in fetal brain, resulting in deterioration of fetal development and the possibilities further.

Ineffective Tissue perfusion : peripheral related to Atherosclerosis

Ineffective Tissue perfusion : peripheral related to Atherosclerosis

Nursing Diagnosis and Interventions   September 19, 2013

Atheroscleros is when the inside of the arteries are thickened, hardened and stiffened, causing the space for blood flow to be narrowed or closed. This will decrease the oxygen supply to local or distant tissues.

Atherosclerosis is a disease of the arterial blood vessels (arteries), in which the walls of the blood vessels become thickened and hardened by "plaques." The plaques are composed of cholesterol and other lipids, inflammatory cells, and calcium deposits.

Cause:

• Coronary Artery Disease -loss of blood to areas of the heart
• Stroke -loss of blood to areas of the brain
• Peripheral Vascular Disease -characterized by leg pain with walking

Symptoms depend on which arteries are affected. For example:

• Coronary (heart) arteries-may cause symptoms of heart disease, such as chest pain
• Arteries in the brain-may cause symptoms of a stroke such as weakness or dizziness
• Arteries in the lower extremities-may cause pain in the legs or feet and trouble walking

Ineffective Tissue perfusion : peripheral

Decrease in oxygen resulting in failure to nourish tissues at the capillary level

Defining Characteristics:

• Edema;
• positive Hoeman's sign;
• altered skin characteristics (hair, nails, moisture);
• weak or absent pulses;
• skin discolorations;
• skin temperature changes;
• altered sensations;
• diminished arterial pulsations;
• skin color pale on elevation, color does not return on lowering the leg;
• slow healing of lesions; cold extremities;
• dependent, blue, or purple skin color

Nursing Diagnosis for Atherosclerosis : Ineffective Tissue perfusion : peripheral related to circulation disorders.

Goal: demonstrate improved perfusion

Outcomes: a peripheral pulse, skin color and temperature is normal, the increase behaviors that increase tissue perfusion.

Nursing Interventions and Rational:

1. Observation of the affected part of skin color.
R /: Skin color typically occurs when cyanosis, cold skin. During the color change, the sick to be cool then throbbing and tingling sensations.

2. Note the decrease in pulse; skin changes (colorless, shiny / tense).
R /: These changes indicate progress or chronic process.

3. View and examine the skin for ulceration, lesions, areas of gangrene.
R /: Lesions can occur from the size of a pin needle to involve all the fingertips and can lead to infection or damage / loss of tissue.

4. Push the right nutrients and vitamins.
R /: The balance of a good diet includes protein and adequate hydration, necessary for healing.

5. Monitior signs of tissue perfusion adequacy.
R /: To know the early signs of impaired perfusion.

6. Encourage the patient performs the exercises, or exercises gradually extremities.
R /: For circulation.