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Thursday, 17 January 2013


Nursing Diagnosis: Constipation related to irregular bowel habit

Purpose: patients can defecate regularly (every day)

Expected outcomes:
  • Defecation can be done once a day
  • The consistency of soft stool
  • Elimination of feces without the need for excessive straining

Nursing Interventions for Constipation

  • Determine the pattern of defecation for clients and train clients to do so.
  • Set the time is right for clients such as defecation after meals.
  • Provide coverage of nutritional fiber according to the indication.
  • Give fluids if not contraindicated 2-3 liters per day.

Acute Pain / Chronic Pain - Rheumatoid Arthritis Nursing Care Plan

Rheumatoid Arthritis

Rheumatoid Arthritis (RA) is a chronic inflammation of the joints. This disease is categorized as an autoimmune disease because people suffering from this condition have antibodies in their blood that target their own body tissues.

Rheumatoid arthritis can attack various organs and tissues in the human body. However, it mainly attacks synovial joints in the hands, wrists, ankles, and knees.

There are, typically, three distinctive types of discomfort which go along with chronic RA. The foremost of these types of discomfort is often called "flair up pain." It is caused by the inflammation of the joints which goes along with periods when your RA is flaring and active.

The next type of rheumatoid pain is often simply called joint pain. It is caused by damage to the joints, which is a consequence of the inflammation. This is the everyday discomfort which is present, even while your RA is not active.

Finally, the very last rheumatoid aspect of the pain equation might be called "emotional pain." It involves the emotions, your psychological well being, and your stress level. The tiredness which you will feel is a part too. This aspect of RA really makes "everything hurt worse."

Management / Treatment of Rheumatoid Arthritis

Nursing Care Plan for Rheumatoid Arthritis


Acute pain related to the presence of surgical wound on abdomen secondary to periampullary carcinoma

Desired Outcome/goal : Patient will get relief from pain as evidenced by a reduction in the pain scale score and verbalization.

Nursing Actions

Primary Prevention
  • Assess severity of pain by using a pain scale
  • Check the surgical site for any signs of infection or complications
  • Support the areas with extra pillow to allow the normal alignment and to prevent strain
  • Handle the area gently. Avoid unnecessary handling as this will affect the healing process
  • Clean the area around the incision and do surgical dressing at the site of incision to prevent any form of infections

Saturday, 12 January 2013

Risk for Infection Care Plan COPD

Risk for Infection NANDA Definition: At increased risk for being invaded by pathogenic organisms

COPD or Chronic obstructive pulmonary disease is one of the most common lung diseases. It makes it difficult to breathe. There are two main forms of COPD:
  • Chronic bronchitis, which involves a long-term cough with mucus
  • Emphysema, which involves destruction of the lungs over time
  • Most people with COPD have a combination of both conditions.

Disturbed Thought Processes - NCP Dementia

Nursing Diagnosis : Disturbed Thought Processes - Dementia Care Plan

Definition: Disruption in cognitive operations and activities.

Dementia is a term that describes a collection of symptoms that include decreased intellectual functioning that interferes with normal life functions and is usually used to describe people who have two or more major life functions impaired or lost such as memory, language, perception, judgment or reasoning; they may lose emotional and behavioral control, develop personality changes and have problem solving abilities reduced or lost.

There are many different causes of dementia, the most common being degenerative neurological diseases, such as Alzheimer's disease, Parkinson's disease, Huntington's disease, and some types of multiple sclerosis. Alzheimer’s disease is the most common, causing fifty percent of all dementia. Other common causes are vascular disorders - such as multiple-infarct dementia, which is caused by multiple strokes; infections - such as HIV dementia complex and Creutzfeldt-Jakob disease, chronic drug use, depression, and types of hydrocephalus - an accumulation of fluid in the brain caused by developmental abnormalities, infections, injury, or brain tumors.

Nursing Interventions :

1. Clients can build a trusting relationship

Expected outcomes:
  • Clients show a sense of fun, friendly facial expression, like shaking hands, making eye contact, sitting side by side.

Interventions :
  • Greet clients well, verbal and non-verbal.
  • Introduce yourself politely.
  • Explain the purpose of the meeting.
  • Honest and keeping promises.
  • Show empathy and accept clients with what it is.
  • Pay attention to the client, and note the basic needs.

2. Clients are able to know / oriented towards people's time and place

Expected outcomes:
  • Clients are able to mention which people around him,
  • Clients are able to mention the day and place the visit.

Interventions :
  • Give the patient the opportunity to get to know the personal belongings, such as a bed, dresser, clothes etc..
  • Give the patient the opportunity to get to know the time using the clock, a calendar that has a sheet with a big day.
  • Give the patient the opportunity to mention his name and family members.
  • Give the opportunity for clients to know where he is.
  • Give praise, if the patient can answer correctly.

3. Patient are able to do daily activities optimally.

Expected outcomes:
  • Patient are able to meet their daily needs independently.

Interventions :
  • Observation of the patient's ability to perform daily activities.
  • Give the patient the opportunity to choose activities that can be done.
  • Help the patient to perform activities that have been chosen.
  • Give praise, if patients can do their activities.
  • Ask the patient's feelings, if able to do activities.
  • Together with the patient, create a schedule of daily activities.

4. Families of patients were able to orient the patient to time, person and place.
Expected outcomes:
  • Families are able to give precise guidance about the time and place and the people around him and the family is able to provide a good attitude to clients.

Interventions :
  • Patient's family, was able to orient the patient to time, person and place.
  • Discuss with the patient's family, ways of orienting time, people and places to the patient.
  • Encourage the family to provide a clock, a calendar with writing great.
  • Discuss with the patient's family, who once owned the ability of the patient.
  • Encourage the family to give praise to the abilities that are still owned by the patient.
  • Encourage the family to monitor the daily activities of patients according to the schedule have been made.
  • Encourage the family to praise, if the patient carried out in accordance with the schedule of activities that have been made.

5. The patient's family can provide the tools needed by the patient to do reality orientation.
Expected outcomes:
  • Clients can / afford things or something that have or are experiencing.

Interventions :
  • Providing the tools needed to conduct patient-oriented.
  • Encourage families to help patients perform activities according to capabilities.

Varicose Veins - 5 Nursing Diagnosis and Interventions

Varicose Veins Care Plan

1. Acute Pain related to tissue ischemia secondary
Goal: Pain is lost or controlled

1) Assess the degree of pain. Note the behavior of protecting the extremities.
R / Degree of pain is directly related to the extent of the circulation shortfall, the inflammatory process.
2) Maintain bed rest during the acute phase.
R / Decrease discomfort in relation to muscle contraction and movement.
3) Elevate the affected extremity.
R / Pushing to facilitate venous return circulation, reduce static formation.
4) Encourage the patient to change positions frequently.
R / Reduce / prevent muscle weakness, helps minimize muscle spasm.
5) Collaboration of drugs as indicated.
R / Reduce pain and reduce muscle tension.

2. Impaired skin integrity related to vascular insufficiency.