Nursing Care Plan for Stroke

Stroke

A stroke, previously known medically as a cerebrovascular accident (CVA), is the rapidly developing loss of brain function(s) due to disturbance in the blood supply to the brain. This can be due to ischemia (lack of blood flow) caused by blockage (thrombosis, arterial embolism), or a hemorrhage (leakage of blood). As a result, the affected area of the brain is unable to function, leading to inability to move one or more limbs on one side of the body, inability to understand or formulate speech, or an inability to see one side of the visual field.

A stroke is a medical emergency and can cause permanent neurological damage, complications, and even death. It is the leading cause of adult disability in the United States and Europe and it is the number two cause of death worldwide. Risk factors for stroke include advanced age, hypertension (high blood pressure), previous stroke or transient ischemic attack (TIA), diabetes, high cholesterol, cigarette smoking and atrial fibrillation. High blood pressure is the most important modifiable risk factor of stroke.

A stroke is occasionally treated in a hospital with thrombolysis (also known as a "clot buster"). Post-stroke prevention may involve the administration of antiplatelet drugs such as aspirin and dipyridamole, control and reduction of hypertension, the use of statins, and in selected patients with carotid endarterectomy, the use of anticoagulants. Treatment to recover any lost function is stroke rehabilitation, involving health professions such as speech and language therapy, physical therapy and occupational therapy.


Causes of Stroke

Blockage of an artery

The blockage of an artery in the brain by a clot (thrombosis) is the most common cause of a stroke. The part of the brain that is supplied by the clotted blood vessel is then deprived of blood and oxygen. As a result of the deprived blood and oxygen, the cells of that part of the brain die and the part of the body that it controls stops working. Typically, a cholesterol plaque in a small blood vessel within the brain that has gradually caused blood vessel narrowing ruptures and starts the process of forming a small blood clot.

Risk factors for narrowed blood vessels in the brain are the same as those that cause narrowing blood vessels in the heart and heart attack (myocardial infarction). These risk factors include :

• high blood pressure (hypertension),
• high cholesterol,
• diabetes, and
• smoking.

Embolic stroke

Another type of stroke may occur when a blood clot or a piece of atherosclerotic plaque (cholesterol and calcium deposits on the wall of the inside of the heart or artery) breaks loose, travels through the bloodstream and lodges in an artery in the brain. When blood flow stops, brain cells do not receive the oxygen and glucose they require to function and a stroke occurs. This type of stroke is referred to as an embolic stroke. For example, a blood clot might originally form in the heart chamber as a result of an irregular heart rhythm, such as occurs in atrial fibrillation. Usually, these clots remain attached to the inner lining of the heart, but occasionally they can break off, travel through the blood stream, form a plug (embolism) in a brain artery, and cause a stroke. An embolism can also originate in a large artery (for example, the carotid artery, a major artery in the neck that supplies blood to the brain) and then travel downstream to clog a small artery within the brain.

Cerebral hemorrhage

A cerebral hemorrhage occurs when a blood vessel in the brain ruptures and bleeds into the surrounding brain tissue. A cerebral hemorrhage (bleeding in the brain) causes stroke symptoms by depriving blood and oxygen to parts of the brain in a variety of ways. Blood flow is lost to some cells. As well, blood is very irritating and can cause swelling of brain tissue (cerebral edema). Edema and the accumulation of blood from a cerebral hemorrhage increases pressure within the skull and causes further damage by squeezing the brain against the bony skull further decreasing blood flow to brain tissue and cells.

Subarachnoid hemorrhage

In a subarachnoid hemorrhage, blood accumulates in the space beneath the arachnoid membrane that lines the brain. The blood originates from an abnormal blood vessel that leaks or ruptures. Often this is from an aneurysm (an abnormal ballooning out of the wall of the vessel). Subarachnoid hemorrhages usually cause a sudden, severe headache, nausea, vomiting, light intolerance, and a stiff neck. If not recognized and treated, major neurological consequences, such as coma, and brain death may occur.

Vasculitis

Another rare cause of stroke is vasculitis, a condition in which the blood vessels become inflamed causing decreased blood flow to brain tissue.

Migraine headache

There appears to be a very slight increased occurrence of stroke in people with migraine headache. The mechanism for migraine or vascular headaches includes narrowing of the brain blood vessels. Some migraine headache episodes can even mimic stroke with loss of function of one side of the body or vision or speech problems. Usually, the symptoms resolve as the headache resolves.


Treatment of a Stroke

Tissue plasminogen activator (TPA)

There is opportunity to use alteplase (TPA) as a clot-buster drug to dissolve the blood clot that is causing the stroke. There is a narrow window of opportunity to use this drug. The earlier that it is given, the better the result and the less potential for the complication of bleeding into the brain.

Present American Heart Association guidelines recommend that if used, TPA must be given within 4 1/2 hours after the onset of symptoms. for patients who waken from sleep with symptoms of stroke, the clock starts when they were last seen in a normal state.

TPA is injected into a vein in the arm but, the time frame for its use may be extended to six hours if it is dripped directly into the blood vessel that is blocked requiring angiography, which is performed by an interventional radiologist. Not all hospitals have access to this technology.

TPA may reverse stroke symptoms in more than one-third of patients, but may also cause bleeding in 6% patients, potentially making the stroke worse.

For posterior circulation strokes that involve the vertebrobasilar system, the time frame for treatment with TPA may be extended even further to 18 hours.

Heparin and aspirin

Drugs to thin the blood (anticoagulation; for example, heparin) are also sometimes used in treating stroke patients in the hopes of improving the patient's recovery. It is unclear, however, whether the use of anticoagulation improves the outcome from the current stroke or simply helps to prevent subsequent strokes (see below). In certain patients, aspirin given after the onset of a stroke does have a small, but measurable effect on recovery. The treating doctor will determine the medications to be used based upon a patient's specific needs.

Managing other Medical Problems

Blood pressure will be tightly controlled often using intravenous medication to prevent stroke symptoms from progressing. This is true whether the stroke is ischemic or hemorrhagic.

Supplemental oxygen is often provided.

In patients with diabetes, the blood sugar (glucose) level is often elevated after a stroke. Controlling the glucose level in these patients may minimize the size of a stroke.

Patients who have suffered a transient ischemic attacks, the patient may be discharged with blood pressure and cholesterol medications even if the blood pressure and cholesterol levels are within acceptable levels. Smoking cessation is mandatory.

Rehabilitation

When a patient is no longer acutely ill after a stroke, the health care staff focuses on maximizing the individuals functional abilities. This is most often done in an inpatient rehabilitation hospital or in a special area of a general hospital. Rehabilitation can also take place at a nursing facility.

The rehabilitation process can include some or all of the following :

1. speech therapy to relearn talking and swallowing;
2. occupational therapy to regain as much function dexterity in the arms and hands as possible;
3. physical therapy to improve strength and walking; and
4. family education to orient them in caring for their loved one at home and the challenges they will face.

The goal is for the patient to resume as many, if not all, of their pre-stroke activities and functions. Since a stroke involves the permanent loss of brain cells, a total return to the patient's pre-stroke status is not necessarily a realistic goal in many cases. However, many stroke patients can return to vibrant independent lives.

Depending upon the severity of the stroke, some patients are transferred from the acute care hospital setting to a skilled nursing facility to be monitored and continue physical and occupational therapy.

Many times, home health providers can assess the home living situation and make recommendations to ease the transition home. Unfortunately, some stroke patients have such significant nursing needs that they cannot be met by relatives and friends and long-term nursing home care may be required. (medicinenet.com)

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Nursing Care Plan for Anemia

Anemia

Anemia (uh-NEE-me-uh) is a condition in which your blood has a lower than normal number of red blood cells.

Anemia also can occur if your red blood cells don't contain enough hemoglobin (HEE-muh-glow-bin). Hemoglobin is an iron-rich protein that gives blood its red color. This protein helps red blood cells carry oxygen from the lungs to the rest of the body.

If you have anemia, your body doesn't get enough oxygen-rich blood. As a result, you may feel tired and have other symptoms. Severe or long-lasting anemia can damage the heart, brain, and other organs of the body. Very severe anemia may even cause death.


Overview

Blood is made up of various parts, including red blood cells, white blood cells, platelets (PLATE-lets), and plasma (the fluid portion of blood).

Red blood cells are disc-shaped and look like doughnuts without holes in the center. They carry oxygen and remove carbon dioxide (a waste product) from your body. These cells are made in the bone marrow—a sponge-like tissue inside the bones.

White blood cells and platelets (PLATE-lets) also are made in the bone marrow. White blood cells help fight infection. Platelets stick together to seal small cuts or breaks on the blood vessel walls and stop bleeding. With some types of anemia, you may have low numbers of all three types of blood cells.

Anemia has three main causes: blood loss, lack of red blood cell production, or high rates of red blood cell destruction. These causes may be due to many diseases, conditions, or other factors.


Outlook

Many types of anemia can be mild, short term, and easily treated. You can even prevent some types with a healthy diet. Other types can be treated with dietary supplements.

However, certain types of anemia may be severe, long lasting, and life threatening if not diagnosed and treated.

If you have signs and symptoms of anemia, see your doctor to find out whether you have the condition. Treatment will depend on the cause and severity of the anemia.
Source : http://www.nhlbi.nih.gov/health/dci/Diseases/anemia/anemia_whatis.html

Nursing Care Plan for Anemia

Nursing Assessment for Anemia

Assessment of patients with anemia (Doenges, 1999) include :

1. Activity / rest
   Symptoms :
   fatigue, weakness, general malaise. Lost productivity: a reduction in enthusiasm for work. Low exercise tolerance. The need for sleep and rest more.
   
   Signs :
   tachycardia / takipnae; dyspnea during work or rest. Lethargy, withdrawn, apathetic, lethargic, and less interested in its surroundings. Muscle weakness, and decreased strength. Ataxia, the body is not upright. Shoulders down, slumped posture, slow, and other signs that indicate fatigue.
2. Circulation
   Symptoms :
   A history of chronic blood loss, such as chronic gastrointestinal bleeding, heavy menstruation, angina, CHF (due to excessive cardiac work). History of chronic infective endocarditis. Palpitations (tachycardia compensation).
   
   Signs :
   Blood pressure: systolic to diastolic steady improvement, and widening pulse pressure, postural hypotension. Dysrhythmias: ECG abnormality, ST segment depression and T wave leveling or depression; tachycardia. The sound of the heart: systolic murmur. Extremity (color): pale skin and mucous membranes (conjunctiva, mouth, pharynx, lips) and the base of the nail. (Note: in black patients, white may appear to be grayish). Leather like waxy, pale or bright lemon yellow. Sclera: blue or pearly white. Slow capillary filling (decreased blood flow to the capillary and vasoconstriction compensation) nails: easily broken, shaped like a spoon (koilonikia). Hair: dry, easily breaking, thinning, gray hair grow prematurely.
3. Integrity ego
   Symptoms :
   Religious beliefs / cultural influence treatment options, such as refusal of blood transfusions.
   
   Signs :
   depression.
4. Elimination
   Symptoms :
   A history of pyelonephritis, kidney failure. Flatulen, malabsorption syndrome. Hematemesis, stool with fresh blood, melena. Diarrhea or constipation. Decrease in urine output.
   
   Signs :
   Abdominal distension.
5. Food / fluid
   Symptoms :
   Decreased dietary input. Painful mouth or tongue, difficulty swallowing (pharyngeal ulcers). Nausea / vomiting, dyspepsia, anorexia. The presence of weight loss. Never satisfied to chew or sensitive to ice, dirt, corn flour, paint, clay, and so forth.
   
   Signs :
   Tongue looks red meat / subtle deficiency of folic acid and vitamin B12. Dry mucous membranes, pale. Skin turgor: ugly, dry, looks shriveled / lost elasticity. Stomatitis and glositis (deficiency status). Lips: selitis, such as inflammatory lips with the corner of his mouth cracked.
6. Neurosensori
   Symptoms :
   Headache, throbbing, vertigo, tinnitus, inability to concentrate. Insomnia, decreased vision, and shadows on the eyes. Weakness, poor balance, unsteady legs, paresthesias hands / feet; klaudikasi. The sensation of being cold.
   
   Signs :
   Sensitive to stimuli, anxiety, depression tend to sleep, apathy. Mental: not able to respond, slow and shallow. Ophthalmic: hemoragis retina. Epitaksis: bleeding from the holes (aplastic). Impaired coordination, ataxia, decreased sense of vibration, and position, positive Romberg sign, paralysis.
7. Pain / comfort
   Symptoms: abdominal pain, headache
8. Breathing
   Symptoms :
   A history of tuberculosis, lung abscess. Short of breath at rest and activity.
   
   Signs :
   Tachypnoea, orthopnea, and dyspnea.
9. Security
   Symptoms :
   A history of work exposure to chemicals,. History of exposure to radiation, either to treatment or accident. History of cancer, cancer therapy. Not tolerant of cold and heat. Previous blood transfusion. Impaired vision, poor wound healing, frequent infections.
   
   Signs :
   A low fever, chills, night sweats, general lymphadenopathy. Ptekie and ekimosis(aplastic).
10. Sexuality
    Symptoms :
    Changes in menstrual flow, such as menorrhagia or amenorrhea. Lost libido (male and female). Imppoten.
    
    Signs :
    Pale vaginal walls.

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Nursing Care Plan for Osteoarthritis

Osteoarthritis

Osteoarthritis (OA) also known as degenerative arthritis or degenerative joint disease, is a group of mechanical abnormalities involving degradation of joints, including articular cartilage and subchondral bone. Symptoms may include joint pain, tenderness, stiffness, locking, and sometimes an effusion. A variety of causes—hereditary, developmental, metabolic, and mechanical—may initiate processes leading to loss of cartilage. When bone surfaces become less well protected by cartilage, bone may be exposed and damaged. As a result of decreased movement secondary to pain, regional muscles may atrophy, and ligaments may become more lax.

Treatment generally involves a combination of exercise, lifestyle modification and analgesics. If pain becomes debilitating joint replacement surgery may be used to improve the quality of life. OA is the most common form of arthritis, and the leading cause of chronic disability in the United States. It affects about 8 million people in the United Kingdom and nearly 27 million people in the United States.


Causes

Exercise, including running in the absence of injury, has not been found to increase one's risk of developing osteoarthritis. Some investigators believe that mechanical stress on joints underlies all osteoarthritis, with many and varied sources of mechanical stress, including misalignments of bones caused by congenital or pathogenic causes; mechanical injury; overweight; loss of strength in muscles supporting joints; and impairment of peripheral nerves, leading to sudden or uncoordinated movements that overstress joints.

Primary
Primary osteoarthritis of the left knee. Note the osteophytes, narrowing of the joint space (arrow), and increased subchondral bone density (arrow).

This type of OA is a chronic degenerative disorder related to but not caused by aging, as there are people well into their nineties who have no clinical or functional signs of the disease. As a person ages, the water content of the cartilage decreases as a result of a reduced proteoglycan content, thus causing the cartilage to be less resilient. Without the protective effects of the proteoglycans, the collagen fibers of the cartilage can become susceptible to degradation and thus exacerbate the degeneration. Inflammation of the surrounding joint capsule can also occur, though often mild (compared to that which occurs in rheumatoid arthritis). This can happen as breakdown products from the cartilage are released into the synovial space, and the cells lining the joint attempt to remove them. New bone outgrowths, called "spurs" or osteophytes, can form on the margins of the joints, possibly in an attempt to improve the congruence of the articular cartilage surfaces. These bone changes, together with the inflammation, can be both painful and debilitating.

A number of studies have shown that there is a greater prevalence of the disease between siblings and especially identical twins, indicating a hereditary basis. Up to 60% of OA cases are thought to result from genetic factors.

Both primary generalized nodal OA and erosive OA (EOA. also called inflammatory OA) are sub-sets of primary OA. EOA is a much less common, and more aggressive inflammatory form of OA which often affects the DIPs and has characteristic changes on X-Ray.

Secondary
This type of OA is caused by other factors but the resulting pathology is the same as for primary OA:

* Congenital disorders of joints
* Diabetes.
* Inflammatory diseases (such as Perthes' disease), (Lyme disease), and all chronic forms of arthritis (e.g. costochondritis, gout, and rheumatoid arthritis). In gout, uric acid crystals cause the cartilage to degenerate at a faster pace.
* Injury to joints, as a result of an accident or orthodontic operations.
* Septic arthritis (infection of a joint )
* Ligamentous deterioration or instability may be a factor.
* Marfan syndrome
* Obesity
* Alkaptonuria
* Hemochromatosis and Wilson's disease


Signs and symptoms

The main symptom is pain, causing loss of ability and often stiffness. "Pain" is generally described as a sharp ache, or a burning sensation in the associate muscles and tendons. OA can cause a crackling noise (called "crepitus") when the affected joint is moved or touched, and patients may experience muscle spasm and contractions in the tendons. Occasionally, the joints may also be filled with fluid. Humid and cold weather increases the pain in many patients.

OA commonly affects the hands, feet, spine, and the large weight bearing joints, such as the hips and knees, although in theory, any joint in the body can be affected. As OA progresses, the affected joints appear larger, are stiff and painful, and usually feel worse, the more they are used throughout the day, thus distinguishing it from rheumatoid arthritis.

In smaller joints, such as at the fingers, hard bony enlargements, called Heberden's nodes (on the distal interphalangeal joints) and/or Bouchard's nodes (on the proximal interphalangeal joints), may form, and though they are not necessarily painful, they do limit the movement of the fingers significantly. OA at the toes leads to the formation of bunions, rendering them red or swollen. Some people notice these physical changes before they experience any pain.

OA is the most common cause of joint effusion, sometimes called water on the knee in lay terms, an accumulation of excess fluid in or around the knee joint.
Source : http://en.wikipedia.org/wiki/Osteoarthritis

 Nursing Care Plan for Osteoarthritis

Nursing Assessment for Osteoarthritis

1. Activity / Rest
   • Joint pain due to movement, tenderness worsened by stress on the joints, stiffness in the morning, usually occurs bilaterally and symmetrically functional limitations that affect lifestyle, leisure, work, fatigue, malaise.
   • Limitation of movement, muscle atrophy, skin: contractor / abnormalities in the joints and muscles.
2. Cardiovascular
   • Raynaud's phenomenon of the hand (eg litermiten pale, cyanosis and redness on the fingers before the color returned to normal.
3. Ego Integrity
   • Stress factors of acute / chronic (eg, financial jobs, disability, relationship factors.
   • Hopelessness and helplessness (inability situation).
   • Threats to the self-concept, body image, personal identity, for example dependence on others.
4. Food / Fluids
   • The inability to produce or consume food or liquids adequately nausea, anorexia.
   • Difficulty chewing, weight loss, dryness of mucous membranes.
5. Hygiene
   • The difficulties to implement self-care activities, dependence on others.
6. Neurosensory
   • Tingling in hands and feet, swollen joints
7. Pain / comfort
   • The acute phase of pain (probably not accompanied by soft tissue swelling in the joints. chronic pain and stiffness (especially in the morning).
8. Security
   • Skin shiny, taut, nodules sub mitaneus
   • Skin lesions, foot ulcers
   • The difficulty in handling the task / household maintenance
   • Mild fever settled
   • Dryness in the eyes and mucous membranes
9. Social Interaction
• Damage interaction with family or others, the changing role: isolation.
10. Counseling / Learning
    • Family history of rheumatic
    • The use of health foods, vitamins, cure disease without testing
    • History pericarditis, valve lesion edge. Pulmonary fibrosis, pleuritis.

Nursing Diagnosis for Osteoarthritis

1. Pain Acute / Chronic related to distention of tissue by the accumulation of fluid / inflammatory process, Liquor joints.
2. Impaired Physical Mobility related to skeletal deformities, pain, discomfort, decreased muscle strength.

Nursing Diagnosis and Nursing Intervention for Osteoarthritis

1. Pain Acute / Chronic related to distention of tissue by the accumulation of fluid / inflammatory process, Liquor joints.
 
Expected Outcomes :

• Showing pain is reduced or controlled
• Looks relaxed, to rest, sleep and participate in activities based on ability.
• Following the therapy program.
• Using the skills of relaxation and entertainment activity in the pain control program.

Nursing Intervention :

• Assess pain; note the location and intensity of pain (scale 0-10). Write down the factors that accelerate and signs of non-verbal pain.
• Give the hard mattress, small pillow. Elevate bed when a client needs to rest / sleep.
• Help the client take a comfortable position when sleeping or sitting in a chair. Depth of bed rest as indicated.
• Monitor the use of a pillow.
• Help clients to frequently change positions.
• Help the client to a warm bath at the time of waking.
Help the client to a warm compress on the sore joints several times a day.
• Monitor temperature compress.
Give a massage.Encourage the use of stress management techniques such as progressive relaxation bio-feedback therapeutic touch, visualization, self hypnosis guidelines imagination, and breath control.Engage in activities of entertainment that is suitable for individual situations.
• Give the drug before activity / exercise that is planned as directed.
• Assist clients with physical therapy.

2. Impaired Physical Mobility related to skeletal deformities, pain, discomfort, decreased muscle strength.  

Expected Outcomes :

Maintain or improve strength and function of the compensation part of the body

Demonstrating techniques / behaviors that allow doing activities.

 
Nursing Intervention

• Monitor the level of inflammation / pain in joints
• Maintain bed rest / sit if necessary
• Schedule of activities to provide a rest period of continuous and uninterrupted nighttime sleep.
• Assist clients with range of motion active / passive and resistive exercise and isometric if possible.
• Slide to maintain an upright position and sitting height, standing, and walking.
• Provide a safe environment, for example, raise the chair / toilet, use a high grip and tub and toilet, the use of mobility aids / wheelchairs rescue.
• Collaboration physical therapist / occupational and specialist vasional.

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Nursing Care Plan for Hypertension

Hypertension

Hypertension (HTN) or high blood pressure is a chronic medical condition in which the systemic arterial blood pressure is elevated. It is the opposite of hypotension. It is classified as either primary (essential) or secondary. About 90–95% of cases are termed "primary hypertension", which refers to high blood pressure for which no medical cause can be found. The remaining 5–10% of cases (Secondary hypertension) are caused by other conditions that affect the kidneys, arteries, heart, or endocrine system.

Persistent hypertension is one of the risk factors for stroke, myocardial infarction, heart failure and arterial aneurysm, and is a leading cause of chronic kidney failure. Moderate elevation of arterial blood pressure leads to shortened life expectancy. Dietary and lifestyle changes can improve blood pressure control and decrease the risk of associated health complications, although drug treatment may prove necessary in patients for whom lifestyle changes prove ineffective or insufficient.


Causes

Essential Hypertension

Essential hypertension is the most prevalent hypertension type, affecting 90–95% of hypertensive patients. Although no direct cause has been identified, there are many factors such as sedentary lifestyle, smoking, stress, visceral obesity, potassium deficiency (hypokalemia), obesity (more than 85% of cases occur in those with a body mass index greater than 25), salt (sodium) sensitivity, alcohol intake, and vitamin D deficiency that increase the risk of developing hypertension. Risk also increases with aging, some inherited genetic mutations, and having a family history of hypertension. An elevated level of renin, a hormone secreted by the kidney, is another risk factor, as is sympathetic nervous system overactivity. Insulin resistance, which is a component of syndrome X (or the metabolic syndrome), is also thought to contribute to hypertension. Recent studies have implicated low birth weight as a risk factor for adult essential hypertension.

Secondary Hypertension


Secondary hypertension by definition results from an identifiable cause. This type is important to recognize since it's treated differently to essential hypertension, by treating the underlying cause of the elevated blood pressure. Hypertension results in the compromise or imbalance of the pathophysiological mechanisms, such as the hormone-regulating endocrine system, that regulate blood plasma volume and heart function. Many conditions cause hypertension, some are common and well recognized secondary causes such as Cushing's syndrome, which is a condition where the adrenal glands overproduce the hormone cortisol. In addition, hypertension is caused by other conditions that cause hormone changes such as hyperthyroidism, hypothyroidism (citation needed), and certain tumors of the adrenal medulla (e.g., pheochromocytoma). Other common causes of secondary hypertension include kidney disease, obesity/metabolic disorder, pre-eclampsia during pregnancy, the congenital defect known as coarctation of the aorta, and certain prescription and illegal drugs.http://en.wikipedia.org

Nursing Care Plan for Hypertension

Nursing Diagnosis for Hypertension

1. High risk for decrease cardiac output related to increased vasoconstriction, myocardial ischemia, ventricular hypertrophy.
2. Impaired sense of comfort : pain (headache) are related to increased cerebral vascular pressure

Nursing Intervention for Hypertension

1. High risk for decrease cardiac output related to increased vasoconstriction, myocardial ischemia, ventricular hypertrophy.

Goal :
vasoconstriction did not occur, myocardial ischemia did not occur

Expected Results :
Patients participating in activities that lower blood pressure / workload of the heart, maintaining normal blood pressure, heart frequency showed stable within the normal range of patients.

Nursing Intervention :

• Monitor blood pressure, measured on both hands, use the cuff and appropriate measurement techniques.
• Note the presence, quality of central and peripheral pulses.
• Auscultation heart tone, and breath sounds.
• Observe skin color, moisture, temperature and capillary filling time.
• Note the general edema.
• Provide quiet environment, comfortable, reduce the activity.
• Maintain restrictions on activities such as rest in bed / chair.
• Helps perform self-care activities as needed.
• Perform good actions such as back and neck massage
• Encourage relaxation techniques, guide the imagination, the transfer activity
• Monitor response to medication to control blood pressure
• Give the restriction of fluid and sodium diet as indicated.
• Collaboration for the provision of drugs as indicated.

2. Impaired sense of comfort : pain (headache) are related to increased cerebral vascular pressure

Goal :
Cerebral vascular pressure did not increase.

Expected Results :
Patients did not reveal a headache and looked comfortable.

Nursing Intervention :

• Maintain bed rest, quiet environment, a little illumination
• Minimize environmental disturbances and stimulation.
• Limit activities.
• Avoid smoking or using nicotine.
• Give the analgesic and sedative drugs to order.
• Give a fun action according to indications such as an ice pack, comfortable position, relaxation techniques, guidance imagination, avoid constipation.

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Nursing Care Plan for Urolithiasis

Urolithiasis

Urolithiasis is the condition where urinary calculi are formed in the urinary tract.

The term kidney stone (or "renal calculus") is sometimes used to refer to urolithiasis in any part of the urinary tract, however it is more properly reserved for stones that are actually in the collecting duct of the kidney itself.

The term nephrolithiasis can be used to describe the condition of having kidney stones, and ureterolithiasis can be used to describe the condition of having stones in the ureter.

Obstruction of the ureter by the kidney stones causes a renal colic attack which is why intense pain is felt in groin and back.

The term bladder stone is more frequently associated with veterinary science.


Causes

Bladder stones can occur if kidney(s), the bladder or urinal tracts get inflamed. Another reason is if a patient has frequent insertion of urinary catheters. Some people who are paralyzed and unable to pass urine require small plastic tubes (catheters) placed in the bladder. These tubes are prone to infection which irritates the bladder resulting in stone formation. Finally kidney stones can travel down the ureter into the bladder and grow in to bladder stones. There is some evidence indicating that chronic irritation of the bladder by retained stones may increase the chance of bladder cancer.


Composition

Urinary stones may be composed of the following substances :

* Calcium oxalate monohydrate (whewellite)
* Calcium oxalate dihydrate (weddellite)
* Calcium phosphate
* Magnesium phosphate
* Ammonium phosphate
* Ammonium magnesium phosphate (struvite)
* Calcium hydroxyphosphate (apatite)
* Uric acid and its salts (urates)
* Cystine
* Xanthine
* Indigotin (rare)
* Urostealith (rare)
* Sulphonamide (rare)


Nursing Care Plan for Urolithiasis

Nursing Assessment for Urolithiasis

History of Nursing and Physical Assessment : based on the Doenges classification (2000), history of nursing that need to be assess are :

1. Activity / rest :
   Symptoms :
   • History of work monotony, physical activity is low, more sedentary.
   • History of working in an environment of high temperature.
   • The limited physical mobility due to other systemic diseases (cerebrovascular injury, long bed rest).
2. Circulation
   Signs :
   • Increased blood pressure (pain, anxiety, kidney failure)
   • Skin warm and reddish or pale.
3. Elimination
   Symptoms :
   • History UTI chronic, History obstruksi
   • Decrease in urine volume
   • Burning, urge to urinate
   • Diarrhea
   Signs :
   • Oliguria, haematuria, piouria
   • Changes in urination pattern
4. Food and liquids :
   Symptoms :
   • Nausea / vomiting, abdominal tenderness
   • History diet high-purine, calcium oxalate or phosphate
   • Hydration is not adequate, do not drink water with enough
   Signs :
   • Distension Abdominal, decline / no noisy intestine
   • Throw up
5. Pain and comfort :
   Symptoms :
   • Pain is severe in the acute phase (colicky pain), location of pain depends on the location of stones (kidney stones cause pain shallow constant)
   Signs :
   • Behavior careful, behavioral distraction
   • Tenderness in the area of kidney pain
6. Security :
   Symptoms :
   • The use of alcohol
   • Fever / chills
7. Counseling / learning :
   Symptoms :
   • History of urinary tract stones in the family, kidney disease, hypertension, gout, UTI Chronic
   • History of disease small intestine, abdominal surgery before, hyperparathyroidism
   • The use of antibiotics, antihypertensives, sodium bicarbonate, alopurinul, phosphate, tiazid, excessive input of calcium or vitamin.

Nursing Diagnosis for Urolithiasis

• Impaired sense of comfort : pain related to an increased frequency / impulse ureteral contraction, tissue trauma, edema formation.
• Changes in elimination of urine related to bladder stimulation by stones, kidney or ureteral irritation, mechanical obstruction, inflammatory.

Nursing Intervention for Urolithiasis

1. Impaired sense of comfort : pain related to an increased frequency / impulse ureteral contraction, tissue trauma, edema formation.

Goal :
The pain may be missing or less

Result Criteria :

• Report the pain disappear
• Relaxed, able to sleep / rest with the appropriate

Intervention :

• Record the location, duration of the intensity (scale 0-10) and deployment. Consider non-verbal signs, for example increased blood pressure, pulse, restless and whimpering.
• Explain the cause of pain and the importance of reporting to the nurse to changing events / characteristics of pain.
• Give the actions comfortable, eg, back massage patients, the environment a break.
• Assist the use of breath focused, the guidance of imagination and the therapeutic activity.
• Note the complaint improvement / establishment of abdominal pain.
• Give appropriate therapy program.

2. Changes in elimination of urine related to bladder stimulation by stones, kidney or ureteral irritation, mechanical obstruction, inflammatory.

Goal :
The elimination of urine in the normal amount

Result Criteria :

• voiding with a normal amount and the pattern usually
• Not have any signs of obstruction

Intervention

• Monitor the income and expenditure and characteristics of urine
• Determine the patient's normal micturition pattern and notice the variation
• Encourage increased fluid intake
• Check all the urine, note the output of stone and send to laboratory for analysis.
• Observation of changes in mental status, behavior or level of consciousness
• Supervise laboratory
• Give appropriate therapy program

Source : http://en.wikipedia.org

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Nursing Care Plan for Chronic Renal Failure - CRF

Chronic Renal Failure - CRF

Chronic renal failure (CRF) is the progressive loss of kidney function. The kidneys attempt to compensate for renal damage by hyperfiltration (excessive straining of the blood) within the remaining functional nephrons (filtering units that consist of a glomerulus and corresponding tubule). Over time, hyperfiltration causes further loss of function.

Chronic loss of function causes generalized wasting (shrinking in size) and progressive scarring within all parts of the kidneys. In time, overall scarring obscures the site of the initial damage. Yet, it is not until over 70% of the normal combined function of both kidneys is lost that most patients begin to experience symptoms of kidney failure.


Signs and Symptoms

Chronic renal failure (CRF) usually produces symptoms when renal function — which is measured as the glomerular filtration rate (GFR) — falls below 30 milliliters per minute (< 30 mL/min). This is approximately 30% of the normal value. When the glomerular filtration rate (GFR) slows to below 30 mL/min, signs of uremia (high blood level of protein by-products, such as urea) may become noticeable. When the GFR falls below 15 mL/min most people become increasingly symptomatic.


Nursing Care Plan for Chronic Renal Failure - CRF

Nursing Assessment for Chronic Renal Failure - CRF

1. Activity / rest

Symptoms :

• The weakness malaise
• Sleep disturbance (insomnia / restless or somnolen)

Signs :

• Muscle weakness, loss of tone, decreased range of motion

2. Circulation

Symptoms :

• History prolonged or severe hypertension
• Palpitations, chest pain (angina)

Signs :

• Hypertension, strong pulse, general and light socket tissue edema in the feet, palms
• The pulse is weak, smooth, orthostatic hypotension
• Cardiac Dysrhythmias
• Pale skin
• Friction rub pericardial
• The tendency of bleeding

3. Ego integrity

Symptoms :

• Stress factors, such as financial problems, relationships with other people
• Feeling helpless, hopeless

Signs :

• Reject, anxiety, fear, anger, personality changes, easily aroused

4. Elimination

Symptoms :

• Decrease in urinary frequency, oliguria, anuria (failure stage)
• Diarrhea, constipation, abdominal bloating

Signs :

• Change the color of urine, the sample thick yellow, brown, reddish, cloudy
• Oliguria or anuria

5. Food / fluid Symptoms :

• Increased weight fast (edema), weight loss (malnutrition)
• Anorexia, nausea / vomiting, heartburn, unpleasant metallic taste in the mouth (breathing ammonia)

Signs :

• abdominal distension / anxiety, liver enlargement (final stage)
• Edema (general, depending)
• Changes in skin turgor / humidity
• Ulceration of gums, bleeding gums / tongue
• Decrease in muscle, subcutaneous fat loss, no powerful appearance

6. Neurosensori Symptoms :

• Muscle cramps / spasms, restless leg syndrome, burning sensation in the head, blurred vision
• soles of feet
• numb / tingling and weakness of extremities especially the lower (peripheral neuropathy)

Signs :

• Impaired mental status, such as inability to concentrate, memory loss, confusion, decreased level of consciousness, decreased field of attention, stupor, coma
• Seizures, muscle fasciculation, seizure activity
• thin hair, thin and brittle nails.

7. Pain / comfort Symptoms :

• headache, muscle cramps / leg pain, pelvic pain

Signs :

• cautious behavior / distraction, anxiety

8. Respiratory Symptoms :

• dyspnea, shortness of breath, paroxysmal nocturnal, cough with or without sputum.

Signs :

• dyspnea, respiratory Tachypnoea kusmaul
• productive cough with watery pink sputum (pulmonary edema)

9. Security Symptoms :

• Itchy skin, there is / recurrent infections

Signs :

• pruritus
• Fever (sepsis, dehydration)

10. Sexuality Symptoms :

• amenorrhea, infertility, decreased libido

11. Social interaction Symptoms :

• Difficulty lowered condition, eg unable to work, maintain the function of roles in the family

12. Counseling

• History of diabetes mellitus in the family (Resti chronic renal failure), polycystic disease, hereditary nephritis, urinary calculus
• History of exposure to toxins, drug samples, environmental toxins
• The use of nephrotoxic antibiotics current / recurrent.

Nursing Diagnosis and Nursing Intervention for Chronic Renal Failure - CRF

1. Decrease in cardiac output related to an increased cardiac load

Goal :
Decrease in cardiac output does not occur with the

Result Criteria :
Maintain cardiac output with evidence of blood pressure and cardiac frequency in the normal range, strong peripheral pulse and equal to the capillary filling time.

Nursing Intervention :

• Auscultation of heart and lung sounds
  Rational : There is an irregular heart frequency tachycardia
• Review of hypertension
  Rational : Hypertension may occur due to disturbances in the system renin-angiotensin-aldosterone system (caused by renal dysfunction)
• Assess complaints of chest pain, perhatikanlokasi, rediasi, weight (scale 0-10)
  Rational : Hypertension and chronic renal failure can cause pain
• Assess the level of activity, response activity
  Rational : Fatigue may accompany chronic renal failure

2. Changes in nutrition: less than the needs associated with anorexia, nausea, vomiting

Objective :
Maintain adequate nutrition inputs

Reasult Criteria :
Shows stable weight

Nursing Intervention :

• Monitor the consumption of food / fluid
  Rational : Identifying nutritional deficiencies
• Watch for nausea and vomiting
  Rational : Symptoms that accompany the accumulation of endogenous toxins that can alter or reduce revenue and require intervention.
• Give the patient a little food but often.
Rational : a smaller portion to increase the input of food
• Increase visits by people closest to during meal.
  Rational : Provide diversion and increase the social aspect.
• Give frequent oral care
  Rational : Reducing the discomfort of oral stomatitis and feeling unwelcome in the mouth that can affect food inputs.

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Nursing Care Plan for Bronchial Asthma

Bronchial Asthma

Bronchial asthma is a disease of the lungs in which an obstructive ventilation disturbance of the respiratory passages evokes a feeling of shortness of breath. The cause is a sharply elevated resistance to airflow in the airways. Despite its most strenuous efforts, the respiratory musculature is unable to provide sufficient gas exchange. The result is a characteristic asthma attack, with spasms of the bronchial musculature, edematous swelling of the bronchial wall and increased mucus secretion. In the initial stage, the patient can be totally symptom-free for long periods of time in the intervals between the attacks. As the disease progresses, increased mucus is secreted between attacks as well, which in part builds up in the airways and can then lead to secondary bacterial infections. Bronchial asthma is usually intrinsic (no cause can be demonstrated), but is occasionally caused by a specific allergy (such as allergy to mold, dander, dust). Although most individuals with asthma will have some positive allergy tests, the allergy is not necessarily the cause of the asthma symptoms.

Symptoms can occur spontaneously or can be triggered by respiratory infections, exercise, cold air, tobacco smoke or other pollutants, stress or anxiety, or by food allergies or drug allergies. The muscles of the bronchial tree become tight and the lining of the air passages become swollen, reducing airflow and producing the wheezing sound. Mucus production is increased.

Typically, the individual usually breathes relatively normally, and will have periodic attacks of wheezing. Asthma attacks can last minutes to days, and can become dangerous if the airflow becomes severely restricted. Asthma affects 1 in 20 of the overall population, but the incidence is 1 in 10 in children. Asthma can develop at any age, but some children seem to outgrow the illness. Risk factors include self or family history of eczema, allergies or family history of asthma. Bronchial asthma causes cough, shortness of breath, and wheezing. Bronchial asthma is an allergic condition, in which the airways (bronchi) are hyper-reactive and constrict abnormally when exposed to allergens, cold or exercise.


Nursing Care Plan for Bronchial Asthma

Nursing Assessment for Bronchial Asthma

1. Past medical history :
   • Assess personal or family history of previous lung disease.
   • Review the history of allergic reaction or sensitivity to the substances / environmental factors.
   • Assess the patient's employment history.
2. Activity
   • The inability to perform activities because of difficulty breathing.
   • The decline in the ability / improvement needs help doing daily activities.
   • Sleeping in a sitting position higher.
3. Respiratory
   • Dipsnea at rest or in response to activity or exercise.
   • Breath worsened when the patient lay supine in bed.
   • Using the drug ventilator, for example: raising the shoulders, widen the nose.
   • The existence of wheezing breath sounds.
   • The recurrent coughing.
4. Circulation
   • The increasing blood pressure.
   • There is an increasing frequency of heart.
   • The color of skin or mucous membranes normal / gray / cyanosis.
   • Redness or sweating.
5. Ego integrity
   • Anxiety
   • Fear
   • Be sensitive to stimuli
   • Restlessness
6. Nutrition
   • 
     
   • Inability to eat due to respiratory distress.
   • Weight loss due to anorexia.
7. Sosal Relations
   • 
     
   • The limited physical mobility.
   • Difficult to talk or stammering.
   • The existence of dependence on others.
8. Sexuality
   • Decrease in libido.

Nursing Diagnosis for Bronchial Asthma

1. Ineffective airway clearance related to the accumulation of mucus.
2. Ineffective breathing pattern related to decreased lung expansion.
3. Impaired nutrition less than body requirements related to inadequate intake.

Nursing Intervention for for Bronchial Asthma

1. Ineffective airway clearance related to the accumulation of mucus.

Goal :
The Way of breath effectively.

Result Criteria :

• Shortness reduced
• Coughing reduced
• Clients can issue a sputum
• Wheezing is reduced / lost.
• Vital signs within normal limits.

Nursing Intervention :

• Auscultation of breath sounds, record the sound of breath, for example: wheezing, erekeis, ronchi.
  Rational : Some degree of bronchial spasms occur with airway obstruction. Faint breath sounds with expiratory wheeze (empysema), no breathing function (severe asthma).
• Review / monitor respiratory frequency, record the ratio of inspiration and expiration.
  Rational : Tachypnoea usually found in some degree and can be found at the reception during the stress / the process of acute infection. Respiratory frequency can be slowed down and elongated than the expiration of inspiration.
• Assess the patient to a safe position, for example: elevation of the head does not sit on the backrest.
  Rational : Elevation head is not easier for respiratory function by using gravity.
• Observation of the characteristic cough, persistent, hacking cough, wet. Auxiliary actions to improve effectiveness cough efforts.
  Rational : The cough can be settled but is not effective, especially on elderly clients, acute pain / weakness.
• Give warm water.
  Rational : use of warm fluids can decrease bronchial spasms.
• Collaboration based drug Spiriva indikasi.Bronkodilator 1 × 1 (inhalation).
  Rational : Freeing airway spasm, wheezing and mucus production.

2. Ineffective breathing pattern related to decreased lung expansion.

Goal :
The pattern of effective breathing.

Result Criteria :

• effective breathing pattern
• The sound of normal breathing or net
• Vital signs within normal limits
• Coughing reduced.
• Expansion of the lungs inflate.

Nursing Intervention :

• Assess respiratory frequency and depth of chest expansion. Record the respiratory effort including the use of auxiliary respiratory muscles / nasal dilation.
  R / velocity usually reaches a depth of respiration varies depending on the degree of respiratory failure. Limited chest expansion associated with atelectasis and / or chest pain.
• Auscultation of breath sounds and record sounds like crekels breath, wheezing.
  R / rhonchi and wheezing accompanying airway obstruction / respiratory failure.
• Elevate the head and help change the position.
  R/ Sitting high enable lung expansion and eases breathing.
• Observation of the pattern of coughing and secretions character.
  R / alveolar congestion often result in cough / irritation.
• Encourage / assist the patient in breathing and coughing exercises.
  R / Can increase / number of sputum where the interference plus the lack of comfortable ventilation and breathing effort.
• Collaboration
  • Provide supplemental oxygen.
  • Provide additional humidifikasi eg nebulizer.
  R / Maximize breath breathe and reduce labor, provide moisture to the mucous membranes and helps thinning secretions.

Source :
http://respiratory-lung.health-cares.net/bronchial-asthma.php

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Nursing Care Plan Acute Renal Failure - ARF

Acute Renal Failure Definition

Acute renal failure (ARF) is the rapid breakdown of renal (kidney) function that occurs when high levels of uremic toxins (waste products of the body's metabolism) accumulate in the blood. ARF occurs when the kidneys are unable to excrete (discharge) the daily load of toxins in the urine.

Based on the amount of urine that is excreted over a 24-hour period, patients with ARF are separated into two groups :

• Oliguric: patients who excrete less than 500 milliliters per day (< 16 oz/day)
• Nonoliguric: patients who excrete more than 500 milliliters per day (> 16 oz/day)

Acute Renal Failure Causes

Causes of acute kidney failure fall into one of the following categories:

• Prerenal: Problems affecting the flow of blood before it reaches the kidneys
  
  
• Postrenal: Problems affecting the movement of urine out of the kidneys
  
  
• Renal: Problems with the kidney itself that prevent proper filtration of blood or production of urine

Acute Kidney Failure Symptoms

The following symptoms may occur with acute kidney failure. Some people have no symptoms, at least in the early stages. The symptoms may be very subtle.

• Decreased urine production
  
  
• Body swelling
  
  
• Problems concentrating
  
  
• Confusion
  
  
• Fatigue
  
  
• Lethargy
  
  
• Nausea, vomiting
  
  
• Diarrhea
  
  
• Abdominal pain
  
  
• Metallic taste in the mouth

Seizures and coma may occur in very severe acute kidney failure.


Nursing Care Plan for ARF - Acute Renal Failure

Acute Renal Failure Nursing Assessment

1. Activity and Rest
   Symptoms:
   Fatigue, weakness, malaese
   
   Signs:
   Muscle weakness and loss of tonus
2. Circulation
   
   Signs:
   Hypotension / hypertension (including malignant hypertension, eclampsia / hypertension due to pregnancy).
   Cardiac dysrhythmia.
   Pulse weak / soft orthostatic hypotension (hipovalemia).
   Strong pulse (hipervolemia).
   Edema public network (including the periorbital area of the sacrum ankle).
   Pale, bleeding tendency
3. Elimination
   Symptoms:
   Changes in the pattern of urination, increased frequency, polyuria (early failure), or decrease the frequency / oliguria (final phase)
   Dysuria, doubt, encouragement, and retention (inflammation / obstruction, infection).
   Abdominal bloating, diarrhea or constipation.
   
   Signs:
   Change the color of dark yellow urine samples, red, brown, cloudy.
   Oliguric (usually 12-21 days), polyuria (2-6 liters / day).
4. Food / Fluids
   Symptoms:
   Increased weight (edema), weight loss (dehydration).
   Nausea, vomiting, anorexia, heartburn
   Use of diuretics
   
   Signs:
   Changes in skin turgor / humidity.
   Edema (General, bottom).
5. Neurosensori
   Symptoms:
   Headaches, blurred vision.
   Muscle cramps / spasms, syndrome "Restless legs".
   
   Signs:
   Impaired mental status, examples of decline in the field of attention, inability to concentrate, memory loss, confusion, decreased level of consciousness (azotemia, electrolyte imbalance / acid-base.
   Seizures, seizure activity.
6. Pain / Leisure
   Symptoms:
   Body aches, headache
   
   Signs:
   Cautious behavior / distraction, anxiety
7. Respiratory
   Symptoms:
   Shortness of breath
   
   Signs:
   Takipnoe, dispnoe, increased frequency, kusmaul, ammonia breath, productive cough with thick pink sputum (pulmonary edema).
8. Comfort
   Symptoms:
   Transfusion reaction
   
   Signs:
   Fever, sepsis (dehydration), or skin ptekie ekimosis, pruritus, dry skin.
9. Counseling / Learning
   Symptoms:
   Family history of polycystic disease, hereditary nephritis, urinary stones, malignancies., a history of exposure to toxins, (drugs, environmental toxins), nephrotic repeated use of drugs eg aminoglycosides, amphotericin, anesthetic vasodilator.

Acute Renal Failure Nursing Diagnosis

1. Excess fluid volume related to decreased Glomerular filtration rate and sodium retention.
2. Imbalanced nutrition: less than body requirements related to catabolic state, anorexia, and malnutrition associated with acute renal failure.
3. Risk for infection related to alterations in the immune system and host defenses.

Acute Renal Failure Nursing Intervention

1.Excess fluid volume related to decreased Glomerular filtration rate and sodium retention.

Goal : Achieving fluid and electrolyte balance

Nursing Intervention

• Monitor urinary output and urine specific gravity; measure and record intake and output including urine, gastric suction, stools, wound drainage, perspiration (estimate).
• Monitor serum and urine electrolyte concentrations.
• Monitor for signs and symptoms of hypovolemia or hypervolemia because regulating capacity of kidneys is inadequate.
• Inspect neck veins for engorgement and extremities, abdomen, sacrum, and eyelids for edema.
• Evaluate for signs and symptoms of hyperkalemia, and monitor serum potassium levels.
• Administer sodium bicarbonate or glucose and insulin to shift potassium into the cells.
• Instruct patient about the importance of following prescribed diet, avoiding foods high in potassium.
• Prepare for dialysis when rapid lowering of potassium is needed.

2. Imbalanced nutrition: less than body requirements related to catabolic state, anorexia, and malnutrition associated with acute renal failure.

Goal :
Maintaining adequate nutrition

Nursing Intervention

• Monitor BUN, creatinine, electrolytes, serum albumin, prealbumin, total protein, and transferrin.
• Be aware that food and fluids containing large amounts of sodium, potassium, and phosphorus may need to be restricted.
• Offer high-carbohydrate feedings because carbohydrates have a greater protein-sparing power and provide additional calories.
• Work collaboratively with dietitian to regulate protein intake according to impaired renal function because metabolites that accumulate in blood derive almost entirely from protein catabolism.
Prepare for hyperalimentation when adequate nutrition cannot be maintained through the GI tract.

3. Risk for infection related to alterations in the immune system and host defenses.

Goal :

Nursing Intervention

• Remove bladder catheter as soon as possible; monitor for UTI.
• Use intensive pulmonary hygiene high incidence of lung edema and infection.
• Monitor for all signs of infection. Be aware that renal failure patients do not always demonstrate fever and leukocytosis.
• If antibiotics are administered, care must be taken to adjust the dosage for renal impairment.

Source : http://www.nephrologychannel.com/arf/index.shtml http://www.emedicinehealth.com/acute_kidney_failure/page3_em.htm#Acute%20Kidney%20Failure%20Symptoms

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Nursing Care Plan for Typhoid Fever

Typhoid Fever

Typhoid fever, also known as enteric fever, is a potentially fatal multisystemic illness caused primarily by Salmonella typhi. The protean manifestations of typhoid fever make this disease a true diagnostic challenge. The classic presentation includes fever, malaise, diffuse abdominal pain, and constipation. Untreated, typhoid fever is a grueling illness that may progress to delirium, obtundation, intestinal hemorrhage, bowel perforation, and death within one month of onset. Survivors may be left with long-term or permanent neuropsychiatric complications.


Pathophysiology

All pathogenic Salmonella species are engulfed by phagocytic cells, which then pass them through the mucosa and present them to the macrophages in the lamina propria. Nontyphoidal salmonellae are phagocytized throughout the distal ilium and colon. With toll-like receptor (TLR)–5 and TLR-4/MD2/CD-14 complex, macrophages recognize pathogen-associated molecular patterns (PAMPs) such as flagella and lipopolysaccharides. Macrophages and intestinal epithelial cells then attract T cells and neutrophils with interleukin 8 (IL-8), causing inflammation and suppressing the infection.

In contrast to the nontyphoidal salmonellae, S typhi enters the host's system primarily through the distal ilium. S typhi has specialized fimbriae that adhere to the epithelium over clusters of lymphoid tissue in the ilium (Peyer patches), the main relay point for macrophages traveling from the gut into the lymphatic system. S typhi has a Vi capsular antigen that masks PAMPs, avoiding neutrophil-based inflammation. The bacteria then induce their host macrophages to attract more macrophages.

It co-opts the macrophages' cellular machinery for their own reproduction as it is carried through the mesenteric lymph nodes to the thoracic duct and the lymphatics and then through to the reticuloendothelial tissues of the liver, spleen, bone marrow, and lymph nodes. Once there, the S typhi bacteria pause and continue to multiply until some critical density is reached. Afterward, the bacteria induce macrophage apoptosis, breaking out into the bloodstream to invade the rest of the body.

The gallbladder is then infected via either bacteremia or direct extension of S typhi –infected bile. The result is that the organism re-enters the gastrointestinal tract in the bile and reinfects Peyer patches. Bacteria that do not reinfect the host are typically shed in the stool and are then available to infect other hosts.

Life cycle of Salmonella typhi.

Signs and Symptoms

Typhoid fever is characterized by a slowly progressive fever as high as 40 °C (104 °F), profuse sweating, gastroenteritis, and nonbloody diarrhea. Less commonly, a rash of flat, rose-colored spots may appear.

Classically, the course of untreated typhoid fever is divided into four individual stages, each lasting approximately one week. In the first week, there is a slowly rising temperature with relative bradycardia, malaise, headache and cough. A bloody nose (epistaxis) is seen in a quarter of cases and abdominal pain is also possible. There is leukopenia, a decrease in the number of circulating white blood cells, with eosinopenia and relative lymphocytosis, a positive diazo reaction and blood cultures are positive for Salmonella typhi or paratyphi. The classic Widal test is negative in the first week.

In the second week of the infection, the patient lies prostrate with high fever in plateau around 40 °C (104 °F) and bradycardia (sphygmothermic dissociation), classically with a dicrotic pulse wave. Delirium is frequent, frequently calm, but sometimes agitated. This delirium gives to typhoid the nickname of "nervous fever". Rose spots appear on the lower chest and abdomen in around a third of patients. There are rhonchi in lung bases. The abdomen is distended and painful in the right lower quadrant where borborygmi can be heard. Diarrhea can occur in this stage: six to eight stools in a day, green with a characteristic smell, comparable to pea soup. However, constipation is also frequent. The spleen and liver are enlarged (hepatosplenomegaly) and tender, and there is elevation of liver transaminases. The Widal reaction is strongly positive with antiO and antiH antibodies. Blood cultures are sometimes still positive at this stage. (The major symptom of this fever is the fever usually rises in the afternoon up to the first and second week.)

In the third week of typhoid fever, a number of complications can occur :

• Intestinal hemorrhage due to bleeding in congested Peyer's patches; this can be very serious but is usually not fatal.
• Intestinal perforation in the distal ileum: this is a very serious complication and is frequently fatal. It may occur without alarming symptoms until septicaemia or diffuse peritonitis sets in.
• Encephalitis
• Metastatic abscesses, cholecystitis, endocarditis and osteitis

The fever is still very high and oscillates very little over 24 hours. Dehydration ensues and the patient is delirious (typhoid state). By the end of third week the fever has started reducing this (defervescence). This carries on into the fourth and final week.

NCP - Nursing Care Plan for Typhoid Fever

Assessment

1. Health History Now
   Why patients enter the hospital and what the major complaints of patients, so it can be enforced priority nursing issues that may arise.
2. Previous Health History
   Does the patient had been ill and treated with the same disease.
3. Family Health History
   Does anyone in the family of patients, the sick like a patient.
4. Psychosocial History
   Intrapersonal: the feeling felt client (anxious / sad)
   Interpersonal: relationship with other people.
5. Patterns of health function
   • The pattern of nutrition and metabolism.
     Usually the client is reduced appetite due to a disruption in the small intestine.
   • Rest and sleep patterns
     During the pain patients feel unable to rest because the patient felt pain in her stomach, nausea, vomiting, sometimes diarrhea.
6. Physical examination
   • Awareness and patient's general condition
     Patient awareness of the need to study the unconscious - not conscious (composmentis - coma) to assess the severity of the patient's disease prognosis.
   • Vital Signs and physical examination Head to foot
     Blood pressure, pulse, respiration, temperature which is a measure of the general condition of patient / patient's condition and includes examination from head to toe by using the principles of inspection, auscultation, palpation, percussion), in addition to body weight were also aware of any decline weight because of the increased nutritional deficiencies that occur, so it can be calculated nutritional needs required.

Nursing Diagnosis

The increase in body temperature associated with the infection process of salmonella thypii

Intervention

Objectives : Normal body temperature
Intervention :

• Observation of the client's body temperature
Rational: to know the changes in body temperature.
• Encourage the family to put on clothing that can absorb sweat like cotton
  Rational: to maintain body hygiene
• Collaboration with physicians in the provision of anti piretik
  Rational: to reduce the heat to the drug

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Nursing Care Plan for Parkinson's Disease

Parkinson's Disease

Parkinson's disease is one of a larger group of neurological conditions called motor system disorders. Historians have found evidence of the disease as far back as 5000 B.C. It was first described as "the shaking palsy" in 1817 by British doctor James Parkinson. Because of Parkinson's early work in identifying symptoms, the disease came to bear his name.

In the normal brain, some nerve cells produce the chemical dopamine, which transmits signals within the brain to produce smooth movement of muscles. In Parkinson's patients, 80 percent or more of these dopamine-producing cells are damaged, dead, or otherwise degenerated. This causes the nerve cells to fire wildly, leaving patients unable to control their movements. Symptoms usually show up in one or more of four ways :

• tremor, or trembling in hands, arms, legs, jaw, and face
• rigidity, or stiffness of limbs and trunk
• bradykinesia, or slowness of movement
• postural instability or impaired balance and coordination.

Though full-blown Parkinson's can be crippling or disabling, experts say early symptoms of the disease may be so subtle and gradual that patients sometimes ignore them or attribute them to the effects of aging. At first, patients may feel overly tired, "down in the dumps," or a little shaky. Their speech may become soft and they may become irritable for no reason. Movements may be stiff, unsteady, or unusually slow.

Symptoms

Tremors- the most noticeable early symptom. It often begins very localised, such as in a finger of one hand. Over time it spreads throughout the whole arm. Tremors often occur when the limb is at rest or when held in a stiff, unsupported position. Tremors also may occur in the lips, feet or tongue.

Bradykinesia- slowness of motion. The individual's movements become increasingly slow and over time muscles may randomly "freeze".

Akinesia- muscle rigidity. Often begins in the legs and neck. These muscles become very stiff. When it affects the muscles of the face the individual adopts a mask like stare.

Digestion problems- the ability to process food slows down, resulting in low energy and constipation.

Depression- Parkinson's causes chemical changes in the brain that may result in depression. This can be an early warning sign, but as depression becomes more common in older adults, it is not often associated with the disease.

Low Blood Pressure- can result in light headedness and fainting.

Temperature sensitivity- perception of temperature can be affected, and may result in hot flashes and excessive sweating.

Leg discomfort- some patients report burning sensations and cramp in the legs.

Balance- There is a progressive loss of coordination and sense of balance, putting the individual at risk of falls.

Source : www.parkinsons.org

Nursing Care Plan for Parkinson's Disease

Nursing Assessment for Parkinson's Disease

1. Assess cranial nerves, cerebral function (coordination) and motor function.
2. Observation of gait and while doing the activity.
3. Review the history of symptoms and their effects on body functions.
4. Assess the clarity and speed of speech.
5. Review the signs of depression.

Nursing Diagnosis for Parkinson's Disease

1. Impaired physical mobility related to muscle stiffness and tremors are marked with :
   Subjective data: client said it was difficult to do activities
   Objective Data: tremors while on the move
2. Impaired compliance with nutrition: less than body requirements related to the difficulty: moving food, chewing, and swallowing, marked with
   Subjective data: client said it was difficult to eat, weight loss
   Objective Data: thin, weighing less than 20% ideal body weight, pale conjunctiva, and mucous membranes pale.
3. Verbal communication disorders related to decreased ability to speak and is characterized by facial muscle stiffness
   Subjective data: client / family say the difficulty in speaking
   Objective Data: elusive words, stony-faced.

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Nursing Care Plan for Benign Postatic Hyperplasia

Assessment

1. Subjective data :
   • The patient complained pain in the wound incision.
   • The patient says can not have intercourse.
   • Patients are always asking action taken.
   • The patient said that urinating is not felt.
2. Objective Data :
   • There incision wound
   • Tachycardia
   • Restless
   • Blood pressure increases
   • Facial expressions of fear
   • Installed catheter

Nursing Diagnosis

Disruption of comfort : pain associated with muscle spasm spincter

Purpose
After 3-5 days of treatment for patients unable to maintain adequate degree of comfort.

Results Criteria

• The verbal pain patients say reduced or lost.
• Patients can rest.

Intervention

• Note the location of pain, intensity (scale 0 - 10)
• Monitor and record the pain, the location, duration and trigger factors and pain relief.
• Observe the signs of non-verbal pain (anxiety, forehead wrinkle, increased blood pressure and pulse)
• Give a warm ompres in the abdomen, especially the lower abdomen.
• Instruct patient to avoid stimulants (coffee, tea, smoking, abdominal strain)
• Set the position of the patient as comfortable as possible, teach relaxation techniques.
• Perform therapeutic treatment of aseptic.
• Report to your doctor if the pain increases.

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Nursing Care Plan For Myocardial Infarction

Myocardial Infarction

Myocardial infarction (MI) is the rapid development of myocardial necrosis caused by a critical imbalance between oxygen supply and demand of the myocardium. This usually results from plaque rupture with thrombus formation in a coronary vessel, resulting in an acute reduction of blood supply to a portion of the myocardium.

Possible causes of Myocardial infarction (MI) are : Coronary artery occlusion, Coronary spasm and Coronary stenosis. There are some risk factors to develop of Myocardial infarction such as :

• Aging
• Decrease serum HDL levels
• Diabetes Mellitus
• Drug use, specifically use of amphetamines or cocaine
• Elevated serum Triglyceride, LDL and Cholesterol levels
• Excessive intake of saturated fats, carbohydrates, or salt
• Family history of CAD
• Hypertension
• Obesity
• Post menopausal women
• Sedentary lifestyle
• Smoking
• Stress

Nursing Care Plan For Myocardial Infarction :

Assessment findings on the patient with myocardial infarction are : Dyspnea, Diaphoresis, Arrhythmias, Tachicardia, Anxiety, Pallor, Hypotension, Nausea and vomiting, Elevated temperature. The specific complain from the patient is crushing substernal chest pain (may radiate to the jaw, back and arms) that unrelieved by rest or nitroglycerin (NGT) tablet.

Nursing Diagnoses:

1. Chest discomfort (pain) due to an inbalance Oxygen (O2) demand supply
2. Potential Arrhythmias related to decrease cardiac output
3. Respiratory difficulties (dyspnoea) due to decrease CO
4. Anxiety & fear of death related to his condition
5. Activity intolerance related to limitations imposed
6. Potential for complications of thrombolytic therapy
7. Discharge medications, follow up & Health teachings

Planing and goals :

• The patient won't develop preventable complication
• The patient will understand the necessary treatment and lifestyle changes.

Intervention:

1. Monitor ECG result to detect ischemia, injury new or extended infarction, arrhythmia, and conduction defects
2. Monitor, record vital signs and hemodynamic variables to monitor response to the therapy and detects complication
3. Administer oxygen as prescribe to improve oxygen supply to the heart
4. Obtain an ECG reading during acute pain to detect myocardial ischemia, injury or infarction
5. Maintain the patient's prescribed diet to reduce fluid retention and cholesterol levels
6. Provided postoperative care if necessary to avoid postoperative complications and help the patient achieve a full recovery
7. Allay the patient's anxiety because the anxiety increase oxygen demands.

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Nursing Care Plan for Pneumonia

Nursing Plan

Breath Pattern ineffectiveness because of pulmonary infection


Characteristics :

Cough (both productive and non productive), shortness of breath, Tachipnea, breath sounds are limited, retraction, fever, diaporesis, ronchii, cyanosis, leukocytosis.


Goal :

Effective breathing pattern characterized by :

• Voice of lung breath clean and the same on both sides
• The temperature of the body within the limits of 36.5 to 37.2 OC
• The rate of breathing in the normal range
• There is no coughing, cyanosis, retraction and diaporesis

Intervention :

• Perform assessments every 4 hours of respiratory rate, temperature, and signs of airway effectiveness.
  Rational: Evaluation and reassessment of the actions that will be / have been granted.
• Perform scheduled Phisioterapi chest
  Rational: Removing the secretion of the airway, preventing obstruction
• Give Oxygen
  Rational: Increased lung tissue oxygen supply
• Give antibiotics and antipyretics, assess the effectiveness and side effects (rash, diarrhea)
  Rational: Eradication of the bacteria as a factor of disturbance causa
• Make checks thoracic photo
  Rational: The evaluation of the effectiveness of the circulation of oxygen, evaluated the condition of lung tissue
• Perform a gradual suction
  Rational: Helping airway clearance
• Record the results of the pulse oximeter when installed, every 2 - 4 hours
  Rational: Periodically Evaluate the success of therapy / health team action.

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Nursing Care Plan Patient Heart Failure

Assessment

1. Left-sided heart failure ; Dyspnea, Crackles, Orthopnea, Paroxysmal noctural dyspnea, Tachypnea, Tachycardia, Gallop rhythm (third or S3 and fourth or S4 heart sound), Fatigue, Anxiety, Arrhythmias and Cough.
2. Righ-sided heart failure ; Dependent edema, Weight gain, Fatique, Jugular vein distention, Tachycardia, Gallop rhythm (S3 or S4), Nausea, Anorexia, Hepatomegaly and Ascites.

Nursing Diagnoses

• Excess fluid volume
• Activity intolerance
• Ineffective health maintenance

Planing and Goals of Nursing Care

• The clients will understand how to cope with necessary lifestyle changes.
• The client won't develop preventable complication
• The client will will understand how to continue therapy at home.

Nursing Intervention For Heart Failure

• Assess cardiovascular status, vital sign and hemodynamic variable to detect signs of reduced cardiac output.
• Assess respiratory status to detect increasing fluid in the lungs and respiratory failure.
• Keep the client in semi-fowler's position to increase chest expansion and improve ventilation.
• Administer medication as prescribed, to enhance cardiac performance and reduce excess fluids.
• Administer oxygen to enhance arterial oxygenation.
• Measure and record intake and output, Intake greater than output may indicated fluid retention.
• Monitor laboratory test result to detect electrolyte imbalances, renal failure, and impaired cardiac circulation.
• Provide suctioning, if necessary assist with turning and encourage coughing and deep breathing to prevent pulmonary complication.
• Restrict oral fluid to avoid worsening the client's condition.
• Weigh the client daily to detect fluid retention. A weight gain of 2lb (0,9 kg) in 1 day or 5 lb (2,3 kg) in 1 week indicates fluid gain.
• Measure and record the client's abdominal girth. An increased in abdominal girht suggests worsening fluid retention and right-sided heart failure.
• Make sure the client maintains a low-sodium diet to reduce fluid accumulation.
• Encourage the client to express feelings, such as a fear of dying to reduce anxiety.

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Nursing Care Plan for Child with Hydrocephalus

Hydrocephalus

The term hydrocephalus is derived from the Greek words "hydro" meaning water and "cephalus" meaning head. As the name implies, it is a condition in which the primary characteristic is excessive accumulation of fluid in the brain. Although hydrocephalus was once known as "water on the brain," the "water" is actually cerebrospinal fluid (CSF) — a clear fluid that surrounds the brain and spinal cord. The excessive accumulation of CSF results in an abnormal widening of spaces in the brain called ventricles. This widening creates potentially harmful pressure on the tissues of the brain.

The ventricular system is made up of four ventricles connected by narrow passages.. Normally, CSF flows through the ventricles, exits into cisterns (closed spaces that serve as reservoirs) at the base of the brain, bathes the surfaces of the brain and spinal cord, and then reabsorbs into the bloodstream.

CSF has three important life-sustaining functions :

1. to keep the brain tissue buoyant, acting as a cushion or "shock absorber";
2. to act as the vehicle for delivering nutrients to the brain and removing waste; and
3. to flow between the cranium and spine and compensate for changes in intracranial blood volume (the amount of blood within the brain).

The balance between production and absorption of CSF is critically important. Because CSF is made continuously, medical conditions that block its normal flow or absorption will result in an over-accumulation of CSF. The resulting pressure of the fluid against brain tissue is what causes hydrocephalus.
www.medicinenet.com

Clinical manifestations :

• Enlarging head circumference
• Irritable, lethargic, apathetic
• Convergent strabismus
• Increased Intra-cranial pressure, decreased consciousness
• Fontanels: tense; bulging
• Manifestation appropriate location in the brain lesions.

Assessment

• Medical history: cerebral trauma, cerebral infections, etc.
• Physical examination: a focus area of the head
• Inspection psychomotor
• Other clinical manifestations
• Check diagnostic

Nursing Diagnosis

• The risk of injury related to increased intra-cranial pressure
• The risk of infection related to mechanical drainage installed
• Changes in tissue perfusion related to interruption of blood flow
• The risk of skin integrity related disorders with an emphasis on the area behind the head
• Impaired family processes related to situational crises (children with physical disorders)

Nursing Intervention

The risk of injury associated with increased intra-cranial pressure

• Observation of Increased intra cranial pressure
• Perform neurological assessment
• Position the patient with safe, elevate the head area
• Avoid the use of sedation.

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Nursing Care Plan for Schizophrenia

Basic Concept of Schizophrenia

Definition

Schizophrenia is a syndrome with various descriptions of the cause (many not yet known) and history (not necessarily chronic or deteriorating) wide, and a number of consequences which depend on consideration of the influence of genetic, physical and socio-cultural (Rusdi Maslim, 1997; 46).

Causes
Offspring
It has been proven by research that the morbidity rate for the half-brother from 0.9 to 1.8%, 7-15% for siblings, for children with one parent who suffered from Schizophrenia 40-68%, 2-15% twins two eggs and one egg twins 61-86% (Maramis, 1998; 215).

Endocrine
This theory is put forward in connection with the frequent occurrence of Schizophrenia at the time of puberty, pregnancy or puerperium time and time climacterium., But this theory can not be proven.

Metabolism
This theory is based for Schizophrenia patients appear pale, unhealthy, a little tip extremity cyanosis, decreased appetite and weight declined and catatonic stupor in patients with decreased oxygen consumption. This hypothesis is still in the proof with the hallucinogenic drug administration.

Central nervous system
Schizophrenia Causes CNS disorders is directed at the diensefalon or brain cortex, but the pathological abnormalities found may be due to postmortem changes or is artefakt in time to make preparations.


Assessment

Assessment is the beginning and the main basis of the assessment phase of nursing process consists of collecting data and formulation of clients' needs or problems.

The data collected consist of biological, psychological, social and spiritual. Grouping of data on mental health pengakajian can also be the predisposing factor, precipitation factor, the assessment of stressors, coping resources and coping abilities possessed clients (stuart and Sunden, 1998). Other studies focus on the way 5 (five) dimensions: physical, emotional, intellectual, social and spiritual. The contents of the study include :

1. Client identity
2. The main complaint / reason for entry
3. Predisposing factors
4. Dimensional physical / biological
5. Psychosocial dimensions
6. Mental status
7. Preparation needs to go home
8. Coping mechanism
9. Psychosocial and environmental problems
10. Medical Aspects

The data obtained through direct observation or examination referred to objective data, the data is delivered in a talk to clients and families through the interview treatment called subjective data.


Nursing Diagnosis

Risk injuring themselves and or others / environment related to changes in sensory perception / hallucinations

General Objectives :
Clients do not mencideri themselves and or others / environment.

Specific objectives :

1. Clients can be a trusting relationship :
   Nursing Intervention :
   • Construct a trusting relationship
     • Regards therapeutic
     • Introducing yourself
     • Explain the purpose of interaction
     • Create a calm environment
     • Create a contract that clearly at every meeting (topics, time and place to talk).
   • Give clients the opportunity to express his feelings.
   • Listen to the client expression of empathy.
2. Clients can recognize hallucinations
   Nursing Intervention :
   • Make frequent contact and brief
     Rational: to reduce the client's contact with the hallucinations.
   • Obeservasi client behavior associated with hallucinations; talk and laugh without the stimulus, kesekitarnya looked as if there is someone to talk.
   • Help clients to know the hallucinations;
     • If the client answered no, proceed; what was said ?
     • Say that the nurse believes the client to hear.
     • Tell that other clients also have such clients.
     • Say that the treatment will help the client.
   • Discuss with the client about;
     • Situations that can cause / not cause hallucinations.
     • Time and frequency of occurrence of hallucinations (morning, afternoon, evening, night or when alone or when upset / sad).
   • Discuss with the client about what is felt when there hallucinations (angry / scared / sad / happy) and the opportunity to express feelings.
3. Clients can control the hallucinations
   Nursing Intervention :
   • Identification with the client ways / actions taken when there hallucinations (sleep / angry / busy myself)
   • Discuss the benefits of the ways in which clients, if useful give a compliment.
   • Discussion of new ways to cut / control the occurrence of hallucinations :
     • Say "I do not want with you" (the hallucinations).
     • Meet with other people (nurses / friends / family members to talk to say hallucinations.
     • Create a schedule of daily activities - the day that hallucinations do not have time to appear.
     • Ask other people (nurses / friends of family members) say hello if looks speak for herself.
   • Help clients decide how to select and train / control the hallucinations gradually.
   • Give the opportunity to perform the way they are trained, evaluated the results and praise when successful.
   • Encourage clients to participate in group activity therapy (stimulation of the realization and perception of orientation).

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