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Self-concept Disturbance : Low Self-esteem (Cause and Effect Mechanism)

Nursing Diagnosis Self-concept Disturbance : Low Self-esteem
Self-concept Disturbance : Low Self-esteem

Definition

Low self-esteem is a negative behavior towards self and abilities, expressed directly or indirectly. (Scultz and Videback, 1998).


Etiology

Negative self-concept system


Signs and symptoms

There are 10 individual way of expressing direct low self esteem (Stuart and Sundeen, 1995)
  • Mocking and self-criticism.
  • Lowering or reduce the dignity of oneself.
  • The guilt or worry.
  • Physical manifestations: high blood pressure, psychosomatic, and substance abuse.
  • Delay and hesitation in taking decisions.
  • Disorders related, withdraw from social life.
  • Withdraw from reality.
  • Destructive self.
  • Damage or harm another person.
  • The hatred and rejection of self.


Cause and Effect Mechanism

Cause

1. Disturbed Body Image.

Definition
Body image disturbance is a change in the perception of the body caused by changes in the size, shape, structure, functions, limitations and meaning of objects in frequent contact with the body, usually the client can not accept his condition, feeling less than perfect then there will be low self esteem.

Signs and symptoms
  • Refuse to see, touch the body parts were changed.
  • Rejecting explanations body changes.
  • Negative perception of the body changes.
  • Reveals despair.
  • Reveals fear.

2. Ideal Self unrealistic

Definition: Ideal themselves are difficult to reach too high and unrealistic, ideal self murky and unclear, tend to be demanding. Failures experienced and fantasy that is too high can not be achieved frustrating and the resulting low self esteem.

Signs and symptoms
  • Feel themselves worthless.
  • Feelings of inadequacy.
  • Guilty feeling.
  • Perceived role strain.
  • Pessimistic view of life.
  • The rejection of the personal ability or inability to obtain a positive appreciation.

Effect

Social isolation: withdrawal

Definition: Withdraw an attempt to avoid interaction with others, avoid contact with other people. In addition to dance themselves an act of escape both the attention and interest of the immediate social environment (self-isolation) (Stuart and Sundeen, 1995).

Signs and symptoms
  • Apathy.
  • Sad facial expression.
  • Afek blunt.
  • Shy away from others.
  • Clients seem to separate themselves with others.
  • Less communication.
  • Less eye contact.
  • Silence.
  • Less mobility.
  • Disruption of sleep patterns (excessive sleep / lack of sleep).
  • Taking sleeping fetal position.
  • Physical health setbacks.
  • Less attention to self-care.

Acute Pain - NCP for Eczema (Dermatitis)


Nursing Care Plan for Eczema (Dermatitis)
Nursing Care Plan for Eczema (Dermatitis)

Dermatitis is an inflammation of the skin, sometimes caused by allergies. Dermatitis is also called eczema.

Types of Dermatitis

Seborrheic Dermatitis : A condition that occurs is red, scaly, itchy rash that occurs in areas of the face (especially the case on the nose and eyebrows), occurs also in the area of the scalp, chest and back. This often occurs when a person in a state of stress, and the possible excessive growth of yeast on the skin. Corticosteroid drugs and drugs that kill microorganisms can overcome this disease.

Contact Dermatitis : Contact dermatitis occurs due to the occurrence of a chemical reaction in contact with skin. Common causes are detergents, nickel, certain plants, and cosmetics. Topical corticosteroid medications which can be a solution for this disease.

Photodermatitis : Photodermatitis occur in people who have abnormalities of the skin sensitive to light. A set point may occur at certain parts of the skin exposed to sunlight.


Nursing Care Plan for Eczema (Dermatitis)

Nursing Diagnosis : Acute Pain related to skin lesions

Goal: Pain is reduced / no pain.

Expected outcomes:
  • Appeasement reached taste disturbances.
  • Expressed with words that itching has subsided.
  • Show no symptoms of the skin excoriations due to scratching.
  • Comply with the prescribed therapy.
  • Keep adequacy skin hydration and lubrication ..
  • Shows the intact skin; skin showed, advances in healthy appearance.

Interventions :

Independent:

1. Check the area involved.
R /: An understanding of the extent and characteristics of the skin include assistance in preparing an intervention plan.

2. Efforts to find the cause of the disorder sense of comfort.
R /: Helps identify the appropriate actions to provide comfort.

3. Record the results of observations in detail by using descriptive terminology.
R /: An accurate description of the skin eruption is necessary for diagnosis and treatment. Many skin conditions seem similar but have different etiologies.

4. Anticipating allergic reactions that may occur; obtain a history of drug use.
R /: Rash thorough especially with sudden onset may indicate an allergic reaction to the drug.

5. Control irritant factors.
R /: Itching aggravated by heat, chemical, and physical.

6. Maintain humidity of approximately 60%; use a humidifier.
R /: With low humidity, the skin will lose water.

7. Maintain a cool environment.
R /: Coolness reduce itching.

8. Use a mild soap or soap made for sensitive skin.
R /: These include the absence of a solution detegen, dyes or reinforcement material.

9. Remove excess clothing or equipment in the bed.
R /: Increase the cool environment.

10. Wash bed linens and clothes with a mild soap.
R /: harsh soaps can cause skin irritation.

11. Stop the repeated exposure to detergents, cleaners and solvents.
R /: Any substance that abolishing water, lipid or protein of the epidermis, will alter the skin barrier function.

12. Use skin care measures to maintain skin integrity and improve patient comfort.
R /: Skin is an important barrier that must be maintained integrity in order to function correctly.

13. Make a compress air with lukewarm water or cold compresses to relieve itching.
R /: Sucking water gradually from gauze compress will soothe the skin and relieve pruritus.

Collaboration:

14. Apply lotion and skin cream immediately after bathing.
R /: This action helps to relieve the symptoms.

15. Instruct the patient to avoid the use of an ointment or lotion purchased without a prescription.
R /: Problems patients can be caused by irritation or sensitization due to the treatment itself.

16. Keep nails patient, always trimmed.
R /: Cutting the nail will reduce skin damage from scratching.

Imbalanced Nutrition: Less Than Body Requirements related to Vertigo


Nursing Care Plan for Vertigo


Imbalanced Nutrition: less than body requirements related to loss of appetite, nausea and vomiting

NOC:
  • Nutritional status: the level of nutrients available to meet the metabolic needs.
  • Nutritional status: food and fluid intake: the amount of food and fluids in the body consumption for the next 24 hours.
  • Nutritional status: nutritional value: adequacy of nutrients consumed by the body.
Achieved after treatment for 3 days

Expected outcomes:
  • Clients will maintain ideal body weight.
  • Clients expressed tolerance to the recommended diet.
  • Maintaining body mass and body weight within normal limits.
  • Reported adequacy level of energy.
NIC interventions:
1. Management of eating disorders.
2. Management of nutrients.
3. Help raise the weight.

Nursing activities:
  • Measure client's weight at appropriate intervals.
  • Determine weight client idea.
  • Provide information regarding the resources available. such as dietary counseling, exercise programs.
  • Discuss with the client regarding a medical condition that affects body weight.
  • Discuss the risks associated with over- or underweight.
  • Help clients to develop a meal plan that is balanced and consistent with the level of energy use.

Nausea related to Vertigo (NCP for Vertigo)

Nausea related to Vertigo (NCP for Vertigo)

Nausea related to Vertigo (NCP for Vertigo)
Nursing Care Plan for Vertigo

NOC:
  • Degree of comfort: a feeling of relief physically and psychologically.
  • Fluid balance: the balance of fluids in the intracellular and extracellular space of the body.
  • Nutritional status: food and fluid intake: the amount of food and fluids into the body within 24 hours.
Achieved after treatment for 3 days

Expected outcomes:
  • Stable weight.
  • There are no sunken eyes.
  • Skin hydration is not compromised.
  • Intake and output balance within 24 hours.
  • Clients reported no nausea.
  • The fluid balance indicator shows 1-5: extreme, severe, moderate, light, no problem.

NIC interventions:
1. Management of fluids: an increase in fluid balance and prevention of complications.
2. Monitoring of fluid: the collection and analysis of client data to regulate fluid balance.
3. Monitoring of nutrients.

Nursing activities:
  • Monitor the subjective symptoms of nausea on the client.
  • Monitor for weight gain.
  • Monitor the level of energy, malaise, fatigue, fatigue.
  • Monitor the skin turgor.
  • Teach clients a deep breath technique to suppress the gag reflex.
  • Teach clients to eat slowly but often.
  • Collaborative: antiemetic drugs in accordance with the recommendation.
  • Raise the head of the bed in the lateral position to prevent aspiration.
  • Monitor the nutritional status.

Nursing Diagnosis and Interventions for Diarrhea in Children

Nursing Care Plan for Diarrhea in Children
Nursing Care Plan for Diarrhea in Children

Nursing Diagnosis 1. Deficient Fluid Volume r / t excessive loss through the feces and vomit and limited intake (nausea).

Intervention and Rationale:
1. Give the oral and parenteral fluids in accordance with rehydration program.
R /: In an effort rehydration to replace fluids out with feces.
2. Monitor intake and output.
R /: Provides information about the status of the balance of fluids to determine the need for fluid replacement.
3. Assess vital signs, signs / symptoms of dehydration and laboratory results.
R /: Assessing the status of hydration, electrolyte and acid-base balance.
4. Collaboration execution of definitive therapy.
R /: Provision of drugs causally important after the cause of diarrhea in the know.


Nursing Diagnosis 2. Imbalanced Nutrition: less than body requirements r / t disruption of nutrient absorption and increase intestinal peristalsis.

Intervention and Rationale:
1. Maintain bed rest and activity restrictions during the acute phase.
R /: Lowering the metabolic needs.
2. Maintain the status of fasting, during the acute phase (according to the program of therapy) and immediately start feeding orally once conditions permit.
R /: oral dietary restrictions may be set during the acute phase to reduce peristalsis causing nutritional deficiencies. Feeding as soon as possible is important, after the client's clinical situation allows.
3. Assist with the implementation of appropriate feeding a diet program.
R /: Meeting the nutritional needs of the client.
4. Collaboration parenteral nutrition as indicated.
R /: Resting gastrointestinal work and overcome / prevent further nutritional deficiencies.


Nursing Diagnosis 3. Acute Pain r / t Hiperperistaltik, irritation perirektal fissure.

Intervention and Rationale:
1. Set a comfortable position for a client, for example with the knee flexed.
R /: Lowering the surface tension of the abdomen and reduce pain.
2. Perform the transfer of activities to provide a sense of comfort like a warm compress massage the back and abdomen.
R /: Increase relaxation, shifting the focus of attention of clients and improve coping skills.
3. Clean the anorectal area with mild soap and water after defecation and provide skin care.
R /: Protecting skin from the stool acidity, prevent irritation.
4. Collaboration of analgesic drugs and or anticholinergic indicated.
R /: Analgesics as anti-pain and anticholinergic agents to reduce spasm of the GI tract can be given appropriate clinical indications.
5. Assess pain (scale 1-10), changes in the characteristics of pain, verbal and non-verbal instructions
R /: Evaluating the development of pain to define interventions.

Nursing Diagnosis 4. Anxiety: family r / t changes in the health status of children.

Intervention and Rationale:
1. Encourage clients to discuss concerns and provide feedback on appropriate coping mechanisms.
R /: To help identify the cause of anxiety and alternative solutions to problems.
2. Emphasize that anxiety is a common problem in the elderly client whose children experienced the same problem.
R /: Help reduce stress by knowing that the client is not the only person experiencing such problems.
3. Create a quiet environment, show a friendly attitude and sincere in helping clients.
R /: Reduce external stimuli that can lead to increased anxiety.

Nursing Diagnosis 5. Knowledge deficit: family: about the condition, prognosis and therapy needs r / t exposure limited information, misinterpretation of information and or cognitive limitations.

Intervention and Rationale:
1. Assess the client's family readiness following study, including knowledge of diseases and their treatments.
R /: The effectiveness of learning is influenced by physical and mental readiness as well as background knowledge before.
2. Describe the process of their disease, its causes and consequences of the disruption of daily fulfillment of daily activities.
R /: An understanding of this issue is important to increase the participation of the client's family and the family in the treatment process client.
3. Explain the purpose of the medication, dosage, frequency and route of administration as well as possible side effects.
R /: Increase understanding client and family participation in treatment.
4. Explain and demonstrate how perineal care after defecation.
R /: Increase the independence and control the client's family to the child care needs.

Causes and Care Plan of Diarrhea in Infants