Clinical Development of Dissociative Identity Disorder

Dissociative identity disorder is a condition where a person has at least two or more conditions are changing ego, which act independently of each other. According to the DSM-IV-TR, dissociative disorder diagnosis can be established when a person has at least two separate ego conditions, or capricious, different conditions in existence, feelings and actions to each other do not affect each other and raised and holding control at different times.

Clinical Development of Dissociative Identity Disorder :

• Individuals have at least two different personalities (the difference in being, feeling, behavior), even contradictory.
• The presence of two or more separate and distinct personality of someone. Each personality has a pattern of behavior, relationships and memory respectively.
• Original personality and fractions sometimes can realize their lost time period, the presence of other personalities. The voice of the other personalities often resonates, go into their consciousness but is not known to belong to anyone.
• Gap in memory may occur if a personality is not related to other personality.
• The existence of different individuals causing disruption in a person's life and can not be cured instantly by drugs.
• It usually appears in early childhood (severe trauma in childhood), but rarely diagnosed until adolescence. More severe than other forms of dissociative disorders.
• Women more than men.

Clinical Development of Depersonalization Disorder

Depersonalization disorder is a condition in which a person's perception or experience of the self-change. In the episode of depersonalization, which is generally triggered by stress, individuals suddenly lose their sense of self. The people with this disorder experience unusual sensory experiences, such as the size of the hands and feet they changed drastically, or their voices sound familiar to their own. The patient also feels are outside their bodies, staring at themselves from a distance, sometimes they feel like a robot, or they seemed to move in the real world.

Clinical Development of Depersonalization Disorder :

• Disorders in which a change in the perception or experience of the individual about himself.
• Individuals feel "not real" and felt alien to themselves and their surroundings, reasonably interfere with the function itself.
• Memory is not changed, but people lose their sense of self.
• These disorders cause stress and lead to bottlenecks in the various functions of life.
• Usually occurs after experiencing severe stress, such as an accident or dangerous situation.
• Usually begins in adolescence and chronic journey (in a long time).

Clinical Development of Dissociative Fugue

Dissociative fugue is memory loss accompanied by leaving the house and create a new identity. In a dissociative fugue, memory loss is greater than the dissociative amnesia. People who have not only experienced a dissociative fugue total amnesia, but suddenly leave home and move to a new identity.

Clinical Development of Dissociative Fugue :

• A disorder in which individuals forget that important personal information and establish a new identity, also moved to a new place.
• Individuals not only suffered amnesia in total, but also suddenly moved (escape) from home and work, as well as forming a new identity.
• Usually occurs after a person experiences some severe stress (conflict with spouse, job loss, suffering because of natural disasters).
• The new identity is often associated with the name, home, work and even a new personality characteristics. In the new life, the individual can succeed despite not being able to remember the past.
• Recovery is usually complete and individuals usually do not remember what happened during the fugue.

Clinical Development of Dissociative Amnesia

Dissociative amnesia is loss of memory after stressful events. A person suffering from this disorder are not able to recall important personal information, usually after a stressful episode.

In total amnesia, the patient does not recognize family and friends, but still have the ability to speak, read and reasoning, also still has the talent and knowledge of the world that had been obtained previously.

Clinical development of dissociative amnesia:

• Loss of memory (in part / whole), usually about important events (stressful, traumatic) has just happened, not due to organic mental disorders, forgetfulness, fatigue, intoxication.
• Individual suddenly becomes unable to recall important personal information (usually after some stressful events).
• During the period of amnesia, behavior or abilities of individuals may not be changed, except that the memory loss caused some disorientation, do not recognize the identity (origin, friends, family, etc.).
• Memory loss.
• Can only for certain events or all events of life.
• Usually takes place in a certain period of time, can be a few hours to several years.
• Memory is usually re-appear suddenly too, complete as before (only less likely to relapse).
• Loss of memory is not the same as those caused by brain damage or because of drug dependence.

Scoliosis - 5 Nursing Diagnosis and Interventions

Scoliosis is a curvature, or lateral curvature of the spine due to the rotation and vertebral deformity.

Three forms of structural scoliosis are:

1. Idiopathic scoliosis is the most common form and classified into 3 groups: infantile, which arise from birth to age 3 years; children, who emerged from the age of 3 years to 10 years; and adolescents, which appears after the age of 10 years (the age of the most common).
2. Congenital scoliosis is scoliosis that causes malformation of one or more vertebral bodies.
3. Neuromuscular scoliosis, children who suffer from neuromuscular diseases (such as brain paralysis, spina bifida, or muscular dystrophy) which directly causes the deformity.

(Nettina, Sandra M.)

Clinical Symptoms

1. Spine curves abnormally to the side.
2. Shoulder or hip and the left and right are not the same height.
3. Back pain.
4. Fatigue in the spine after sitting or standing for long.
5. Severe scoliosis (curvature greater than 60) can cause respiratory problems.

Nursing Diagnosis and Interventions for Scoliosis

1. Ineffective Breathing Pattern related to emphasis the lung.
Goal: effective breathing pattern.
Intervention:

• Assess respiratory status every 4 hours.
• Help and teach the patient to do deep breaths every 1 hour.
• Set the semi-Fowler position bed to improve lung expansion.
• Auscultation of the chest to listen for breath sounds every 2 hours.
• Monitor vital signs every 4 hours.

2. Acute pain: back related to body position tilted laterally.
Goal: pain is reduced / lost.
Intervention:

• Assess the type, intensity, and location of pain.
• Adjust the position of which can increase the sense of comfort.
• Maintain a quiet environment to improve comfort.
• Teach relaxation and distraction techniques to divert attention, thus reducing pain.
• Encourage regular postural exercises to improve posture.
• Teach and encourage use of the brace to reduce pain during activity.
• Collaboration in providing analgesic to relieve pain.

3. Impaired physical mobility related to an unbalanced posture.
Objective: To improve physical mobility.
Intervention:

• Assess the level of physical mobility.
• Increase activity if pain is reduced.
• Teaching aids and active joint range of motion exercises.
• Involve the family in performing self-care.
• Increase return to normal activity.

4. Disturbed Body Image or Self-concept disturbance related to kelateral tilted posture.
Objective: To enhance the image of the body.
Intervention:

• Instruct to express feelings and problems.
• Give supportive environment.
• Help the patient to identify positive coping styles.
• Give realistic expectations and goals for the short term to facilitate the achievement.
• Give rewards for tasks performed.
• Encourage communication with people nearby and need socialization with family and friends.
• Give encouragement to care for themselves as tolerated.

5. Knowledge Deficit related to lack of information about the disease.
Goal: understanding of the treatment program.
Intervention:

• Explain about the state of the disease.
• Emphasize the importance and benefits of maintaining the recommended exercise program.
• Tell us about the treatment of: name, schedule, purpose, dosage, and side effects.
• Demonstrate the installation and maintenance brace or corset.

Decreased Cardiac Output - NCP for Angina Pectoris

Nursing Diagnosis for Angina Pectoris : Decreased cardiac output related to contraction disorders

NOC :

• Cardiac Pump Effectiveness
• Circulation Status
• Vital Sign Status

Outcomes :

• Vital Signs within the normal range (blood pressure, pulse, respiration).
• Can tolerate the activity, there is no fatigue.
• No pulmonary edema, peripheral and no ascites.
• There is no loss of consciousness.

NIC

Cardiac Care

• Evaluation of chest pain (intensity, location, duration).
• Note the presence of cardiac dysrhythmias.
• Note the reduction in signs and symptoms of cardiac putput.
• Monitor cardiovascular status.
• Monitor respiratory status that indicates heart failure.
• Monitor the abdomen as an indicator of decreased perfusion.
• Monitor fluid balance.
• Monitor any changes in blood pressure.
• Monitor the patient's response to the effects of antiarrhythmic treatment.
• Set exercise and rest periods to avoid fatigue.
• Monitor the patient's activity tolerance.
• Monitor the presence of dyspnea, fatigue, tachypnea and orthopnoea.
• Suggest to reduce stress.

Vital Sign Monitoring

• Monitor BP, pulse, temperature, and RR.
• Note the fluctuations in blood pressure.
• Monitor VS when the patient is lying down, sitting, or standing.
• Auscultation of blood pressure in both arms and compare.
• Monitor BP, pulse, RR, before, during, and after activity.
• Monitor the quality of the pulse.
• Monitor the presence of pulsus paradoxus and pulsus alterans.
• Monitor the number and monitors the heart rhythm and heart sounds.
• Monitor respiratory rate and rhythm.
• Monitor lung sounds, abnormal breathing patterns.
• Monitor temperature, color, and moisture.
• Monitor peripheral cyanosis.
• Monitor the presence of Cushing's triad (widened pulse pressure, bradycardia, increased systolic).
• Identify the cause of vital sign changes.

Ineffective Airway Clearance related to Bronchiectasis

Nursing Diagnosis for Bronchiectasis : Ineffective Airway Clearance related to increased mucus production and decreased ability to cough effectively.

Goal: Effective airway, eliminating the quantity of sputum viscosity to improve pulmonary ventilation and gas exchange.

Outcomes:

• can demonstrate effective coughing,
• can mention the ways to lower the viscosity of secretions,
• no additional breath sounds,
• normal breathing (16-20 x / min) without the use of auxiliary breathing muscles.

Nursing Interventions:

1. Assess color, consistency, and amount of sputum.
R /: Characteristics of sputum may indicate the severity of the obstruction.

2. Adjust the position semifowler.
R /: Enhance chest expansion.

3. Teach cough effectively.
R /: Cough is controlled and can effectively facilitate the embedding secret spending airway.

4. Help clients practice a deep breath.
R /: maximum ventilation opening the airway lumen and increase the secret movement into the large airway to be issued.

5. Maintain fluid intake at least 2500 ml / day unless indicated.
R /: Adequate hydration helps thin the secret and effective airway clearance.
In addition, to increase the client's fluid intake is a tendency to breathe through the mouth which increases water loss. Inhalation of evaporated water vapor is also helpful because it can moisturize the bronchial branching.

6. Perform chest physiotherapy with postural drainage techniques, percussion, and vibration chest.
R /: Postural drainage with percussion and vibration using the help of gravity to help increase the secretion that can be easily removed or inhaled. Therapies that can dilate the bronchi as aerosol therapy, bronchodilator aerosolization, or intermittent positive pressure breathing action (IPPB), must be given before postural drainage due to the secretion will flow more easily after tracheo-bronchial branching dilated. The client is instructed to breathe and cough effectively to help remove secretions. Postural drainage is usually performed when the client wakes up, to get rid of secretions that have accumulated throughout the night, and before the break, to improve the quality and quantity of sleep.

7. Collaboration of bronchodilators.
R /: Provision of bronchodilators via inhalation will go directly to the area that experienced the bronchus spasm resulting in faster dilated.


Ineffective Airway Clearance related to Bronchiectasis

Ineffective Airway Clearance related to Sinusitis - Nursing Diagnosis and Interventions

Pneumonia Nursing Diagnosis - Ineffective Airway Clearance and Impaired Gas Exchange

Nursing Assessment for Social Isolation : Withdrawal

Social Isolation : Withdrawal


1. Identity
Often found at an early age or first appear at puberty.

2 Main Complaint
The main complaint is usually a result of the decline will and emotional shallowness.

3 Factors Predisposing
Predisposing factors are closely associated with etiological factors that heredity, endocrine, metabolic, central nervous system, the weakness of the ego.

4 Psychosocial
a. Genogram
Schizophrenic parents, one son 7-16% possibility of schizophrenia, when both suffered 40-68%, from 0.9 to 1.8% stepsister possibility, the twin brother of 2-15%, 7-15% sibling.

b. Self-Concept
Setbacks will and shallowness of the patient's emotions will affect the patient's self-concept.

c. Social Relations
Clients tend to withdraw from social environment, starry-eyed, silent.

d. Spiritual
Spiritual activity declines with the decline of the will.

5. Mental Status
a. Appearance
The patient appeared lethargic, lackluster, hair disheveled, shirt buttons are not right, not locked zipper, clothes not replaced, clothes upside as a manifestation of the willingness of the patient's deterioration.

b. Talks
Tone was low, slow, less talk, apathetic.

c. Activity of Motor
Activities undertaken are not varied, the tendency to defend one of its own position (catalepsy).

d. Emotions
Shallow emotions.

e. Afec
Superficially, there is no facial expression.

d. Interaction During Interview
Tend not cooperative, less eye contact, do not want to stare at the speaker, silent.

e. Perception
There were no hallucinations or delusions.

d. Thinking process
Impaired thought processes are rarely found.

e. Awareness
Altered consciousness, and the ability to make contact with the outside world and the restriction itself is disturbed at the level does not correspond to reality (qualitative).

f. Memory
Not found specific disorders, the orientation, time, good people.

g. Capability assessment
Can not make decisions, can not act in a situation, always giving reasons although the reasons are unclear or imprecise.

6. Everyday Needs

At the beginning people pay less attention to himself and his family, the more backward the job due to setbacks will. Interest to meet their own needs greatly decreased in terms of eating, urination / defecation, bathing, dressing, sleeping intirahat.

Mobilization and Immobilization Definition

Mobilization Definition

• Mobility is the movement that gave freedom and independence for a person. (Ansari, 2011).
• Mobilization is a condition where the body can perform activities freely. (Kosier, 1989 cit Ida 2009)
• Mobilization is the ability to move freely, easily and regularly which aims to meet the needs of a healthy life. Mobilization is necessary for enhancing the health, slow the disease process, especially degenerative diseases and to actualization. Mobilization led to improved circulation, creating a deep breath and stimulate gastrointestinal function returns to normal, thrust to move the foot and lower leg as soon as possible, usually within 12 hours. (Mubarak, 2008).
• Mobility or mobilization of an individual's ability to move freely, easily and regularly with the aim to meet the needs of the activity in order to maintain health. (AA Aziz, 2006)
• Mobililis / Mobilisation is effortless motion / move. (Christine Brooker, 2001)
• Physical mobility is a state when a person experiences or even at risk of physical limitations and is not immobile. (Doenges, M.E, 2000)
• Mobility or mobilization is the ability of individuals to move freely, easy, and organized with the aim to meet the needs of the activity in order to maintain health.

Immobilization Definition

• Immobility is broadly defined as the level of activity that is less than optimal mobility. (Ansari, 2011).
• Immobilization is a condition in which the patient must rest in bed, do not move actively due to a variety of diseases or disorders of the organs of a physical or mental. Can also be interpreted as a state do not move / bedrest constant for 5 days or more due to changes in physiological function (Bimoariotejo, 2009).
• Immobility (immobilization) is a state of not moving / bed rest (bed rest) for 3 days or more (Adi, 2005). A state of physical movement limited ability to independently experienced by a person (Pusva, 2009).
• Immobilization is a relative condition, where individuals not only lose the ability to move in total, but also decreased the activity of the normal habits. (Mubarak, 2008).
• Impaired physical mobility (immobilization) is defined by the North American Nursing Diagnosis Association (NANDA) as a situation where an individual is experiencing or at risk of physical movement limitations. Individuals who are experiencing or at risk of physical movement limitations, among others: the elderly, individuals with the disease who experienced a loss of consciousness of more than 3 days or more, the individual who lost the use of anatomic result in physiological changes (loss of motor function, a client with a stroke, a wheelchair user client) , the use of external tools (such as a cast or traction), and restriction of movement of volunteers (Potter, 2005).
• Immobilization is the inability of a person to move his own body. Immobilization is said to be a major risk factor in the emergence of decubitus wounds both in hospitals and in the community. This condition can increase the time an emphasis on skin tissue, and subsequently lead to lower circulation decubitus sores. Immobilization in addition to directly affect the skin, also affects several organs. For example, in the cardiovascular system, peripheral blood circulation disorders, respiratory system, lower lungs to pick up oxygen movement of air (lung expansion) and result in decreased oxygen intake to the body Lindgren et al, 2004)

Related Articles :

Nursing Interventions : Impaired Physical Mobility - Rheumatoid Arthritis

Impaired Physical Mobility of Parkinson's Disease

Nursing Interventions for Impaired Physical Mobility related to Stroke

Acute Pain and Impaired Physical Mobility NCP for Tuberculous Meningitis

Risk-prone Health Behavior - Atherosclerosis Care Plan

Risk-prone Health Behavior

Domain 1: Health promotion

Class 2: Health management

Definition: Impaired ability to modify lifestyle/behaviors in a manner that improves health status

Defining characteristics:

• can not act anything to prevent health problems

Related factors:

• a variety of stressors
• smoke

NOC:

Cardiac disease self management: personal action to manage heart disease, its treatment and prevent disease progression.

Indicators:

• accept health provider’s diagnosis
• monitors pulse rate and rhythm
• monitors blood pressure
• limits fat and colesterol intake
• follows recommended diet
• monitors body weight
• uses effective weight control strategies
• maintain optimum weight
• participate in smoking cessation regiment
• participate in recommended exercise program
• balances activity and rest

NIC:

Smoking cessation assistance: helping another to stop smoking

Activity:

• Determine the patient's readiness to quit smoking
• Monitor the patient's readiness to quit smoking
• Provide clear and consistent advice to quit smoking
• Provide another option is best as a substitute for smoking

Oral health restoration: promotion of healing for a patient who has an oral mucosa or dental lesion
Activity:

• Using a soft toothbrush to clean the gums and oral cavity
• Stopping the consumption of alcohol and cigarettes
• Instructing the patient to brush teeth after eating

10 Symptoms of Anemia

Here are some signs that indicate that you have anemia, as reported by Boldsky.

1. Pale eyelids.

It is easy to detect anemia with seeing eyes. When you stretch the eyelids and under the eyes attention. You will notice that the inside of the eyelids pale.

2. Often fatigue.

If you feel tired all the time for a month or more, it could be that you have a number of red blood cells is low. Body's energy supply is very dependent on the oxidation and red blood cells The lower the red blood cells, the level of oxidation in the body part is reduced.

3. Frequent nausea.

Those who are anemic often experience symptoms morning sickness or nausea as soon as they get up from bed.

4. Headache.

People who are anemic often complain of headaches constantly. Shortage of red blood makes the brain is deprived of oxygen. This often causes headaches.

5. Pale fingertips.

When you press the tip of the finger, the area will turn into red. But, if you have anemia, your fingertips will be a white or pale.

6. Shortness of breath.

Low blood counts lowers oxygen levels in the body. This makes people with anemia often feel shortness of breath or frequent panting when doing everyday activities such as walking.

7. Irregular heartbeat.

Palpitations is the medical term for irregular heartbeat, too strong or has abnormal speed. When the body is deprived of oxygen, the heart rate increases. This causes the heart to beat irregularly and rapidly.

8. Pale face.

If you have anemia, your face will look pale. The skin will also be a yellowish white.

9. Hair loss.

Hair loss can be a symptom of anemia. When the scalp is not getting enough food from the body, you will experience hair thinning rapidly.

10. Decreased immunity.

When your body has very little energy, immunity, or the body's ability to fight disease go down. You will easily fall sick or exhausted.

Activity Intolerance - Nursing Diagnosis Interventions for Anemia

Nursing Care Plan for Anemia

Anemia is a condition in which the number of red blood cells or hemoglobin in the red blood cells are below normal. Red blood cells contain hemoglobin which carries oxygen in the role of the lungs and deliver it to all parts of the body.

A common cause of anemia among others; iron deficiency, intestinal bleeding, bleeding, genetically, deficiency of vitamin B12, folic acid drawback, bone marrow disorders.

Causes and Risk Factors

Blood is composed of plasma and cells. There are three types of blood cells:

• White blood cells (leukocytes). These blood cells are useful to fight infection.
• Platelets. These blood cells help the blood clot when injured.
• White blood cells (erythrocytes). The red blood cells carry oxygen from the lungs through the bloodstream to the brain and other organs and tissues.

The body requires a supply of oxygen to function. Red blood cells contain hemoglobin which is a protein that is like the iron that give red color.

Many blood cells are produced by bone marrow. To be able to produce red blood cells and hemoglobin, your body needs iron, minerals, protein and other vitamins from the foods you eat.


Nursing Diagnosis for Anemia : Activity Intolerance related to imbalance between oxygen demand and supply


Goal : to maintain / improve ambulation / activity .

Outcomes:

• Reported an increase in exercise tolerance ( including activities of daily living )
• Showed decreased signs of physiological intolerance , for example pulse , respiration , and blood pressure was within the normal range .

Intervention

1 . Assess the patient's ADL ability .
Rationale : influence the choice of intervention / assistance .

2 . Assess loss or impaired balance , gait and muscle weakness .
Rationale : show changes due to vitamin B12 deficiency neurological affects patient safety / risk of injury .

3 . Observation of vital signs before and after the activity .
Rationale : cardiopulmonary manifestations of heart and lung efforts to bring an adequate amount of oxygen to the tissues .

4 . Provide quiet environment , limit visitors , and reduce noise , keep bed rest when indicated .
Rationale : improving breaks to lower the body's need for oxygen and lowering strain the heart and lungs .

5 . Use energy -saving techniques , instruct the patient to rest, if there is fatigue and weakness , instruct the patient to perform activities of his best . ( without imposing themselves ) .
Rationale : increase activity gradually to normal and improve muscle tone / stamina without drawbacks . Boost the self-esteem and sense of control .

Decreased Cardiac Output - NCP for Angina Pectoris

Nursing Care Plan for Angina Pectoris

Angina pectoris is a clinical syndrome characterized by paroxysmal episodes or pain or feeling of pressure in front of the chest. (Brunner and Suddart, 1997)

Angina usually occurs when exercise, severe emotional stress, or after a heavy meal. During these periods, the heart muscle demands more blood oxygen than the narrowed arteries can provide. Angina typically lasts from 1 to 15 minutes and is relieved by rest or by placing a nitroglycerin tablet under the tongue. Nitroglycerin relaxes blood vessels and lowers blood pressure. Both rest and nitroglycerin reduce myocardial demand for oxygen, thus freeing angina.

Factors causing angina pectoris, among others:

• Insufficient oxygen supply to the cells of the heart muscles compared needs.
• When the move, especially heavy activity, increased cardiac workload. Pumping heart muscle stronger.
• History of smoking (both active smokers and passive smokers)
• Angina is caused by a decrease in blood flow to the heart area. Sometimes, other types of heart disease or uncontrolled hypertension can lead to angina.
• Arteriosclerosis is a general term for several diseases, in which the arterial wall becomes thicker and less flexible which fatty materials collect under the inner lining of the artery wall.
• Coronary artery spasm.
• Severe anemia.
• Arthritis.
• Aortic insufficiency.

Nursing Diagnosis : Decreased Cardiac Output

Goal: An increase in cardiac output.

Outcomes:
Patients reported a reduction in episodes of dyspnea, angina and dysrhythmias showed increased activity tolerance, clients participating in behaviors or activities that lower cardiac work.

Interventions :

1. Monitor vital signs, eg heart rate, blood pressure.
R :/ tachycardia can occur due to pain, anxiety, hypoxemia, and decreased cardiac output. Changes in BP (hypertension or hypotension) due to cardiac response.

2. Evaluation of mental status, note the occurrence of confusion, disorientation.
R :/ Lowering the perfusion of the brain can result in changes in sensorium.

3. Note the presence of skin color and pulse quality.
R :/ decreased peripheral circulation when cardiac output falls, making the skin pale and gray (depending on the degree of hypoxia) and a decline in the strength of peripheral pulses.

4. Maintaining bed rest in a comfortable position during an acute episode.
R :/ Lowered oxygen consumption or decrease the need for labor and the risk of myocardial decompensation.

5. Give adequate rest periods. Assist in or perform self-care activities, as indicated.
R :/ saving energy, lowering cardiac work.

6. Monitor and record the effects or loss of drug response, blood pressure levels, heart rate and rhythm.
R :/ desired effect to decrease myocardial oxygen demand by decreasing ventricular stress. Drug with negative inotropic content can decrease perfusion to the ischemic myocardium. The combination nitras and beta-blockers may exert its effects on cardiac output collected.

7. Assess for signs and symptoms of CHF.
R :/ Angina only pathological symptoms caused by myocardial ischemia, a disease which affects the function of the heart became decompensated.

8 Give the drug as indicated: calcium channel blockers.
R :/ Although different in its form, calcium channel blockers play an important role in preventing and eliminating ischemia originator of coronary artery spasm and decrease vascular resistance, thus reducing BP and heart work.

Nursing Care Plan for Conjunctivitis

Conjunctivitis is an inflammation of the conjunctiva, the mucous membrane that covers the white part of the eye and the inner eyelid. Condition characterized by red eyes is the most common eye disorder in children.

Types of Conjunctivitis

Conjunctivitis can be caused by bacterial infections, viral infections, allergies or irritation.:

• Bacterial conjunctivitis : infections caused by bacteria, such as staphylococci, streptococci or Haemophilus. Eyes are usually issued dung eyes yellow / greenish yellow which may spread to the lashes and cause a sticky eyelids, especially in the morning.
• Viral conjunctivitis : an infection caused by a virus called adenovirus, often associated with the common cold. Types of conjunctivitis are very contagious among humans and can cause epidemics. Eye redness and discharge may be watery. Often the swollen eyelids. This type of conjunctivitis may also spread to the cornea and cause blurred vision.
• Allergic Conjunctivitis : allergy due to objects such as pollen, dust mites, or dust. Itchy eyes and redness that may be accompanied by many tears, eyelid crusting and photophobia (eye glare). This condition can occur at certain times of the year, for example during a drought when a lot of pollen and dust flying through the air. Children who have a history of allergic conjunctivitis often have other atopic diseases such as allergic rhinitis, eczema or asthma.
• Irritation Conjunctivitis : caused by chlorine in the pool, smoke, or steam.

In addition, the newborn child called neonatal conjunctivitis or ophthalmia neonatorum which is transmitted during the birth process and including sexually transmitted diseases such as gonorrhea or chlamydia infection. In small infants, symptoms of watery eyes and more eyes droppings caused by tear drainage problems that have not evolved than conjunctivitis. The condition is known as the naso-lacrimal duct obstruction, which will disappear when the baby is getting older.


Nursing Diagnosis for Conjunctivitis

1. Acute pain related to inflammation of the conjunctiva.
2. Anxiety related to lack of knowledge about the disease process.
3. Risk of spread of infection associated with inflammatory processes.
4. Impaired self-concept (body image decreases) related to the change of the eyelids (swelling / edema).
5. Risk for injury related to limited vision.

5 Nursing Diagnosis for Meningitis

Meningitis is a severe inflammation of the lining of the brain. Inflammation that may occur after the attacks of otitis media, mastoid inflammation, brain abscess, even inflamed tonsils. Something cracked in the skull or a penetrating head injury that may result in meningitis. (Clifford R Anderson: 1975)

Meningitis is an acute infection of the lining of the meninges (the membranes covering the brain and spinal cord). These infections can be caused by:
Bacteria, such as : pneumococcus, meningecoccus, stapilococcus, streptococcus, salmonella, etc..
Viruses, such as : Haemophilus influenza and herpes simplex.

Signs and Symptoms

1. Changes in cerebral tissue perfusion related to cerebral edema / obstruction of blood flow.
2. Acute pain associated with the infection process.
3. Damage to physical mobility related to neuromuscular damage.
4. High risk of trauma / injury associated with generalized seizure activity.
5. Associated with an increased risk of exposure to infection, the immune system is weak.

Characterized by symptoms of refusing to eat, less to suck reflexes, vomiting, diarrhea, lack of muscle tone, weak cry. In children and adolescents usually there are signs and symptoms of high fever, headache, vomiting, sensory changes, seizures, easily stimulated, photo phobia, delirium, hallucinations, manic, stupor, coma, neck stiffness, positive Kernig and Brudzinski, ptechial (show meningococcal infection).


1. Ineffective tissue perfusion (cerebral)
related to:
cerebral edema,
hypovolemia.

2. Risk for injury
related to:
generalized seizures / focal,
general weakness,
vertigo.

3. Acute Pain
related to:
inflammatory process,
toxin in the circulation.

4. Impaired physical mobility
related to:
Neuromuscular damage,
decrease in strength.

5. Anxiety
related to:
crisis situation,
threat of death.

Acute Pain - Nursing Care Plan for Vertigo

Vertigo is a symptom of dizziness that can happen to anyone, ranging from mild symptoms to severe. Vertigo can be characterized by a sense of dizziness as the head spins and inverted vision. As a result, patients experience dizziness highly and will not be able to get up because of the dizziness.

Dizziness is actually a common symptom associated with various disorders. Causes of dizziness may be related to the nervous system, but can be derived from ENT, heart, eyes, and even psychologically.

After all dizziness complaints, ranging from mild to severe, should be evaluated carefully in order to clear the source and the cause can be found so that the obtained optimal treatment or handling.

Symptoms of vertigo can be triggered by various things, such as a hormonal disorder that is marked by the presence of acne, fatigue, stress, lack of rest and so on.


Nursing Diagnosis for Vertigo : Acute Pain related to stress and tension, irritation / nerve pressure, vasospasm, increased intracranial pressure.

Characterized by :
Stating that pain is influenced by such factors, changes in position, changes in sleep patterns, anxiety.

Goal : Pain is lost or reduced

Outcomes:

• The client expresses pain is reduced.
• Normal vital signs.
• The client appeared calm and relaxed.

Intervention :
1. Monitor vital signs , intensity / pain scale
Rationale : Identify and facilitate the nursing action.

2. Encourage clients to rest in bed.
Rational : the break to reduce the intensity of pain.

3. Adjust the position of the patient as comfortable as possible.
Rational : the exact position reduces stress and prevent muscle tension and reduce pain.

4. Teach relaxation techniques and breathing deeply.
Rationale : relaxation reduces tension and makes the feeling more comfortable.

5. Collaboration for providing analgesic.
Rationale : useful analgesic to reduce pain so that the patient becomes more comfortable.

Acute Pain related to Angina Pectoris

Nursing Care Plan for Angina Pectoris

Angina Pectoris is described as severe chest pain that results from insufficient blood flow to the heart. The main cause is a coronary artery disease called atherosclerosis, or a clogging of the arteries.

Signs and symptoms of this heart related condition may include tightness or pressure in the chest that may radiate to the left shoulder and arm, or possibly the neck and jaw. Other symptoms may include difficulty breathing, anxiety, sweating, or pale skin.

During an attack of angina pectoris, a person should rest and take nitroglycerin under the tongue. This may be enough to eliminate the symptoms. Depending on possible underlying conditions, other treatment such as balloon angioplasty or other surgeries may be recommended, or certain medications (beta-blockers, daily aspirin) may be needed. In most cases, a patient can benefit from a healthy diet and exercise, which should be prescribed by their doctor.


Nursing Diagnosis : Acute Pain related to Myocardial Ischemia

Goal: reduced pain / resolved
Outcomes:

• Stated / said no pain,
• Reported angina episodes decreased in frequency, duration and severity.

Nursing Interventions :

1. Instruct the patient to notify nurse quickly in the event of chest pain.
R:/ pain and decreased cardiac output can stimulate the sympathetic nervous system to release large amounts of nor epinephrine, which increases platelet aggregation and thromboxane A2 issued. Pain can not be detained cause vasovagal response, reducing BP and heart rate.

2. Identification of the precipitating factors, if any: frequency, duration, intensity and location of pain.
R: / Help distinguish early chest pain (stable angina usually ends 3 to 5 minutes while unstable angina longer and can last more than 45 minutes).

3. Evaluation report pain in the jaw, neck, shoulder, hand or arm (especially on the left side).
R:/ Cardiac pain may spread to the sample surface pain more often innervated by the same spinal level.

4. Instruct the patient to bed rest during episodes of angina.
R:/ Reduce myocardial oxygen demand in order to minimize the risk of tissue injury or necrosis.

5. Elevate the head of the bed when the patient is short of breath.
R:/ Facilitate the exchange of gases to reduce repetitive hypoxia and shortness of breath.
Monitor the speed or rhythm of the heart.

6. Monitor the speed or rhythm of the heart.
R:/ Patients with unstable angina have increased dysrhythmias, acute life-threatening, which occurs in response to ischemia and or stress.

7. Panatau vital signs every 5 minutes during an attack of angina.
R:/ BP can rise early with respect to sympathetic stimulation , then dropped when the cardiac output is affected.

8 . Maintain a calm, comfortable environment, limit the visitor when necessary.
R:/ mental or emotional stress increase myocardial work.

9. Give soft foods. Let the patient rest for 1 hour after eating.
R :/ Lowering myocardial work in connection with the work of digestion, lowers the risk of angina attacks

Constipation related to Pregnancy (Hyperemesis Gravidarum)

Hyperemesis gravidarum is vomiting occur until 20 weeks gestation, so great, where all that is eaten and drunk vomited thereby affecting the general condition and daily work, weight loss, dehydration, there is acetone in the urine.

Nausea and vomiting are the most common disorders in the first trimester of pregnancy or approximately 6 weeks after the last menstrual period for 10 weeks. Approximately 60% -80% primigravida and 40% -60% multigravida experience nausea and vomiting. However, these symptoms become more severe in only 1 in 1000 pregnancies. Hyperemesis gravidarum began to occur in the fourth to the tenth week of pregnancy and then will be improved in general at the age of 20 weeks, but in some cases can be continued through the next stage pregnant. Gadsby, et.al (1993) reported that almost 10% of clients found the symptoms persist hyperemesis gravidarum during pregnancy.

Constipation is a digestive condition where you can bowel movement fewer than three times a week. Constipation is a common problem experienced by pregnant and postpartum women. High pregnancy hormones make muscles in the bowel movements slowed. in addition, a growing fetus will push the large intestine that interfere with their normal activities. Postpartum, constipation caused by episiotomy (cutting and suturing the vaginal lips back), or at cesarean delivery, which temporarily paralyzed colon because of the anesthesia. Have a variety of symptoms such as constipation hard bowel movements, bloating, or form a hard dirt and small. so you should already feel the urge to defecate, get to the bathroom because it would hold a bowel movement make constipation worse.


Nursing Diagnosis and Interventions for Constipation

Goal: constipation resolved

Expected outcomes:

• Perform regular defecation.
• Mushy stool consistency.

Intervention:

1. Teach the importance of a balanced diet.
2. Review the list of foods that contain lots of fresh fruits in shell, husk, beans, breads and cereals, fruits and cooked vegetables, fruit juices, including nearly 800 grams of fruits and vegetables every day for normal defecation.
3. Gradually increase fiber foods.
4. Encourage fluid intake 2 liters (8-10 glasses) unless there are contraindications.
5. Encourage drinking a glass of warm water 30 minutes before breakfast.
6. Teach how to memasase lightly on the lower abdomen while on the toilet.

Rational:

1. The balance of dietary intake to minimize the incidence of constipation eat.
2. Consuming foods that contain lots of fiber will prevent the client from constipation.
3. Maintaining a balance of fiber in the body of the patient to meet the needs of fiber body.
4. Consuming enough fluids to maintain adequate metabolic status.
5. Drinking warm water can induce intestinal stimulation for defecation.
6. Doing abdominal massage can stimulate the intestinal peristaltic causing defecation desire.

Nursing Diagnosis and Interventions for Pain

Nursing Diagnosis for Pain

1. Acute Pain
related to physical injury, reduction of blood supply, process of giving birth

2. Chronic Pain
related to the malignancy

3. Anxiety
related to pain that is felt

4. Ineffective individual coping
related to chronic pain

5. Impaired physical mobility
related to musculoskeletal pain

6. Risk for injury
related to lack of perception of pain


Nursing Interventions for Pain

Nurses develop a plan of nursing diagnoses that have been made. Nurses and clients together to discuss realistic expectations of action to overcome the pain, the degree of recovery of the expected pain, and the effects that must be anticipated in the client's lifestyle and function. Expected outcomes and goals of nursing and nursing diagnoses were selected based on the client's condition. The general objective of nursing care with pain are as follows:

• Clients feel healthy and comfortable
• Clients retain the ability to perform self-care
• Clients maintain physical function and psychological currently owned
• Client describes the factors that cause pain
• Clients use the therapy given safely at home

Source : http://nursing-care-plan.blogspot.com/2011/11/nursing-care-plan-for-pain-assessment.html