Nursing Care Plan for Gastroenteritis

Gastroenteritis

Gastroenteritis is a condition that causes irritation and inflammation of the stomach and intestines (the gastrointestinal tract). Diarrhea, crampy abdominal pain, nausea, and vomiting are the most common symptoms.


Viral infection is the most common cause of gastroenteritis but bacteria, parasites, and food-borne illness (such as shellfish) can be the offending agent.


Many people who experience the vomiting and diarrhea that develop from these types of infections or irritations think they have "food poisoning," and they may indeed have a food-borne illness. Many people also refer to gastroenteritis as "stomach flu," although influenza has nothing to do with the condition.


Travelers to foreign countries may experience "traveler's diarrhea" from contaminated food and unclean water.

• The severity of infectious gastroenteritis depends on the immune system's ability to resist the infection. Electrolytes (these include essential elements of sodium and potassium) may be lost as you vomit and experience diarrhea.
• Most people recover easily from a short bout with vomiting and diarrhea by drinking fluids and easing back into a normal diet. But for others, such as infants and the elderly, loss of bodily fluid with gastroenteritis can cause dehydration, which is a life-threatening illness unless the condition is treated and fluids restored.

Symptoms

By definition, gastroenteritis affects both the stomach and the intestines, resulting in both vomiting and diarrhea.


Common symptoms may include:

• Low grade fever to 100°F (37.7°C)
• Nausea with or without vomiting
• Mild-to-moderate diarrhea:
• Crampy painful abdominal bloating

More serious symptoms

• Blood in vomit or stool
• Vomiting more than 48 hours
• Fever higher than 101°F (40°C)
• Swollen abdomen or abdominal pain
• Dehydration - weakness, lightheadedness, decreased urination, dry skin, dry mouth and lack of sweat and tears are characteristic findings.

Nursing Diagnosis

Fluid volume deficit and electrolyte less than body requirements related to excessive fluid output.
Imbalanced Nutrition, Less Than Body Requirements related to nausea and vomiting.



Intervention 

Diagnosis 1

Imbalanced Nutrition, Less Than Body Requirements related to nausea and vomiting.


Purpose :
Nutritional needs disturbances resolved

Outcomes :

Clients increased nutritional intake, low dietary portion 1 provided, nausea, vomiting does not exist.

Intervention:

• Examine patterns of clients and nutritional changes. Measure client weight. Examine factors cause the fulfillment of nutritional disorders. Perform physical examination of the abdomen (palpation, percussion, and auscultation). Give your diet in warm conditions and the small but frequent portions. Collaboration with the team in determining diet nutrition clients.

Diagnosis 2

Fluid volume deficit and electrolyte less than body requirements related to excessive fluid output.


Purpose :
Fluid and electrolyte Devisit resolved

Outcomes:Signs of dehydration are not there, mouth and lip mucosa moist, well-balanced fluid exchange


Intervention

• Observation of vital signs. Observation of signs of dehydration. Measure the liquid infut and output (balanc ccairan). Provide and encourage families to provide a lot of drinking more or less 2000 - 2500 cc per day. Collaboration with physicians in providing therafi fluid, electrolyte lab tests. Collaboration with a team of nutrition in low-sodium fluids.

Nursing Care Plan for Anorexia Nervosa

NCP For Anorexia Nervosa

Anorexia nervosa is an eating disorder characterized by refusal to maintain a healthy body weight and an obsessive fear of gaining weight. It is often coupled with a distorted self image which may be maintained by various cognitive biases that alter how the affected individual evaluates and thinks about her or his body, food and eating. Persons with anorexia nervosa continue to feel hunger, but deny themselves all but very small quantities of food. The average caloric intake of a person with anorexia nervosa is 600-800 calories per day, but there are extreme cases of complete self-starvation. It is a serious mental illness with a high incidence of comorbidity and the highest mortality rate of any psychiatric disorder.

Anorexia most often has its onset in adolescence and is most prevalent among adolescent girls. However, it can affect men and women of any age, race, and socioeconomic and cultural background. Anorexia nervosa occurs in females 10 times more than in males.
(wikipedia)

Nursing Care Plan for Anorexia Nervosa
NCP for Anorexia Nervosa

Assessment and collection of data

1. record inadequate nutrition
2. record the weight loss of 15% below normal, or more
3. examine skin turgor
4. leg muscle strength
5. amenorrhea
6. electrolyte imbalance
7. dental erosion

Examination information:

1. anemia
2. electrolyte imbalance
3. electrocardiogram

Nursing diagnosis, planning, and implementation
Imbalances nutrition: less than body requirements related to inadequate intake, vomiting

Expected outcome : diet according to individual body weight.

1. monitoring of patient weight
2. monitoring vital signs and laboratory
3. increase patient confidence
4. give eat little but often

Body image disorders associated with psychosocial and cognitive changes

Expected outcome: patients verbally expressed satisfaction with the body.

1. review and document verbal and nonverbal responses
2. listen to patients and bring to reality
3. monitor the expression of negative patient and document patient's verbal and nonverbal
4. examine the need referral to counseling and social services
5. give an award verbally

Evaluation

1. Patients receive the appropriate weight
2. patients satisfied with her ​​body
3. patients to assess the positive effect in the body.

Nursing Care Plan for Appendicitis

NCP For Appendicitis

Appendicitis

Appendicitis is a condition characterized by inflammation of the appendix. It is classified as a medical emergency and many cases require removal of the inflamed appendix, either by laparotomy or laparoscopy. Untreated, mortality is high, mainly because of peritonitis and shock. Reginald Fitz first described acute and chronic appendicitis in 1886, and it has been recognized as one of the most common causes of severe acute abdominal pain worldwide. A correctly diagnosed non-acute form of appendicitis is known as "rumbling appendicitis".


Signs & Symptoms

For the most part symptoms relate to disturbed function of bowels. Pain first, vomiting next and fever last has been described as classic presentation of acute appendicitis. Pain starts mid abdomen,and except in children below 3 years, tends to localize in right iliac fossa in a few hours. This pain can be elicited through various signs. Signs include localized findings in the right iliac fossa. The abdominal wall becomes very sensitive to gentle pressure (palpation). Also, there is severe pain on suddenly releasing a deep pressure in lower abdomen rebound tenderness. In case of a retrocecal appendix, however, even deep pressure in the right lower quadrant may fail to elicit tenderness (silent appendix), the reason being that the cecum, distended with gas, prevents the pressure exerted by the palpating hand from reaching the inflamed appendix. Similarly, if the appendix lies entirely within the pelvis, there is usually complete absence of the abdominal rigidity. In such cases, a digital rectal examination elicits tenderness in the rectovesical pouch. Coughing causes point tenderness in this area (McBurney's point) and this is the least painful way to localize the inflamed appendix. If the abdomen on palpation is also involuntarily guarded (rigid), there should be a strong suspicion of peritonitis requiring urgent surgical intervention.
wikipedia


Assessment

1. Patient Identity
   The identity of the client's name, age, sex, marital status, religion, tribe / nation, education, occupation, income, address and registration number.
2. Nursing History
   • Health history now : complaints of pain in post operative wounds, nausea, vomiting, increased body temperature, increased leukocytes.
   • Health history of the past
3. Physical examination
   • Cardiovascular System: To check vital signs, presence or absence of jugular vein distension, pale, edema, and abnormal heart sounds.
   • Hematological System: To determine whether there is increase in leukocytes is a sign of infection and bleeding, nosebleeds splenomegaly.
   • Urogenital System: There are at least tension of the bladder and back pain complaints.
   • Musculoskeletal System: To determine whether there is difficulty in movement, pain in bones, joints and there is a fracture or not.
   • The immune system: To determine whether there is lymph node.
4. Examination Support
   • Routine Blood tests: to determine an increase in leukocytes is a sign of infection.
   • Abdominal x-ray examination: to know the existence of post-surgical complications.

Nursing Diagnosis

Pain related to abdominal wound incision in the lower right quadrant of postoperative


Nursing Intervensi

Goal :
Pain is reduced / lost

Result Criteria :
Seemed relaxed and could sleep properly.

Intervention :

• Assess the scale of pain location, pain characteristics and report changes accordingly.
• Maintain a break with the semi powler.
• Encourage early ambulation.
• Give your entertainment activities.
• Collaborate with team doctors in the provision of analgesics.

Rational :

• Useful in the supervision and efficient medicine, healing progress, changes and characteristics of pain.
• Eliminating stress is increased by abdominal supine position.
• Improve kormolisasi organ function.
• Increase relaxation.
• Pain relief.

Nursing Care Plan for Psoriasis

Psoriasis is a chronic immune-mediated disease that appears on the skin. It occurs when the immune system sends out faulty signals that speed up the growth cycle of skin cells. Psoriasis is not contagious. There are five types of psoriasis: plaque, guttate, inverse, pustular and erythrodermic. The most common form, plaque psoriasis, is commonly seen as red and white hues of scaly patches appearing on the top first layer of the epidermis (skin). Some patients, though, have no dermatological symptoms.

In plaque psoriasis, skin rapidly accumulates at these sites, which gives it a silvery-white appearance. Plaques frequently occur on the skin of the elbows and knees, but can affect any area, including the scalp, palms of hands and soles of feet, and genitals. In contrast to eczema, psoriasis is more likely to be found on the outer side of the joint.

The disorder is a chronic recurring condition that varies in severity from minor localized patches to complete body coverage. Fingernails and toenails are frequently affected (psoriatic nail dystrophy) and can be seen as an isolated symptom. Psoriasis can also cause inflammation of the joints, which is known as psoriatic arthritis. Between 10% and 40% of all people with psoriasis have psoriatic arthritis.(wikipedia)

1. Impaired skin integrity related to inflammation between dermal - epidermal secondary to psoriasis
2. Fear related to changes in appearance
3. Anxiety related to changes in health status secondary to psoriasis
4. Impaired self-concept related to the crisis of confidence
5. Lack of knowledge related to not knowing the source of information.

Nursing Intervention and Rationale Nursing Care Plan Psoriasis

Assess skin condition
R /: Knowing the damage to the skin to make appropriate interventions.

Observation of vital signs
R /: Knowing the patient's health status changes.

Assess skin color changes.
R /: Knowing the effectiveness of the circulation and identify the occurrence of complications.

Keep the infected area clean and dry.

R /: Helps accelerate the healing process.

Support the preferred type of coping when the adaptive mechanism is used.
R /: Anger is an adaptive response that accompanies fear.

Encourage to express his feelings.
R /: Can reduce the stress on patients.

Suggest to use normal coping mechanisms.
R /: Accuracy in the use of coping is one way of reducing fear.

Assess the level of anxiety and discuss the cause if possible
R /: Identify the specific issues will enhance the ability of individuals to deal with more realistic.

Give the patient time to express the problem and the encouragement of free expression, such as anger, fear, doubt
R /: In order for the patient to feel accepted.

Explain all procedures and treatments
R /: Ignorance and lack of understanding can lead to anxiety

Discuss alternative coping behaviors and problem-solving techniques
R /: Reduce patient anxiety

Assess the patient's behavioral changes such as introvert, shy dealing with others.
R /: Knowing the level of distrust of the patient in determining interventions.

Be realistic and positive during treatment, in patient counseling.
R /: Improving trust and partnership between the nurse-patient relationship.

Give hope within the parameters of individual situations.
R /: Improve positive behavior

Give positive reinforcement of progress.
R /: Words can support the strengthening of positive coping behaviors.

Encourage family interaction.
R /: Maintaining lines of communication and providing ongoing support to patients.

Nursing Care Plan for Tuberculosis TB

Tuberculosis (TB) is a bacterial infection caused by a germ called Mycobacterium tuberculosis. The bacteria usually attack the lungs, but they can also damage other parts of the body. TB spreads through the air when a person with TB of the lungs or throat coughs, sneezes or talks. If you have been exposed, you should go to your doctor for tests. You are more likely to get TB if you have a weak immune system.

Symptoms of TB in the lungs may include

• A bad cough that lasts 3 weeks or longer
• Weight loss
• Coughing up blood or mucus
• Weakness or fatigue
• Fever and chills
• Night sweats

If not treated properly, TB can be deadly. You can usually cure active TB by taking several medicines for a long period of time. People with latent TB can take medicine so that they do not develop active TB

Centers for Disease Control and Prevention

Nursing Care Plan for Pulmonary Tuberculosis

Nursing Assessment

1. IdentityThe assessment includes name, age, sex, religion, ethnicity, education, employment and housing clients. In addition, it is necessary also reviewed the name and address of responsible person, and its relationships with clients.
2. History Formerly Disease
   Review the history of the disease who had suffered from childhood to adulthood, including the experience of surgery or injury resulting from accidents, it is important to expose the client health issues that may cause more severe complications of the disease is tuberculosis.
3. Disease History Now
   • Main Complaint
     Complaints night fever, night sweats, coughing up phlegm / bleeding, difficulty breathing, fatigue, night sweats, decreased appetite, weight loss.
   • History of Disease
     How long illness experienced, the things that lighten / aggravate the disease.
   • Efforts taken to resolve complaints.
4. Health Patterns
   1. Activity / Rest
      Clients may experience areduction in weakness ,shortness of breath due to work, difficulty sleeping at night ,night fever ,chills or sweating . Characterized by muscle weakness, pain, and shortness (advanced stage).
   2. Ego Integrity
      Clients can experience stress, financial problems, feeling helpless / hopeless marked denial, anxiety, fear, easily aroused.
   3. Nutrition / fluid
      Clients may complain of poor appetite, unable to digest, weight loss. Marked by poor skin turgor, dry / scaly skin, loss of muscle / subcutaneous fat loss.
   4. Pain / Leisure
      Increased chest pain due to recurrent cough, marked behavioral distraction and anxiety.
   5. Respiratory
      Clients complain of cough, productive or non-productive, short breath, a history of tuberculosis or exposure to an infected individual. Characterized by increased frequency, deaf percussionist and a decrease fremitus, breath sounds: decreased, tubular and / or pectoral whisper above the lesion area. Krekels recorded over the lung during inspiration stale quickly after a short cough. Characteristics of green sputum / purulent, mukoid yellow, or blood spots, mental changes (advanced stage).
   6. Social interaction
      Clients feel isolated / rejection due to communicable diseases, unusual patterns of change in responsibilities or change in physical capacity to perform the role.
   7. Counseling / learning
      Characterized by a family history of suffering from tuberculosis, the general inability / poor health status, failed to improve / recurrence of disease and do not want to participate in therapy.
   (Doenges, 2000, p. 240-241)

Nursing Diagnosis for Pulmonary Tuberculosis

1. Ineffective Airway Clearance related to :
   • thick secretions
   • weakness, bad cough efforts
   • edema, tracheal / pharyngeal
2. Impaired Gas Exchange related to :
   • reduced effectiveness of lung surface
   • atelectasis
   • alveolar capillary membrane damage
   • thick secretions
   • bronchial edema
3. Risk For Infection and spread of infection related to :
   • decreased immune system
   • cilia function declines
   • secretions that settle
   • tissue damage due to the spread of infection
   • malnutrition
   • contaminated by the environment
   • lack of knowledge about infectious germs
4. Imbalanced Nutrition Less than Body Requirements related to :
   • fatigue
   • coughing frequently
   • the production of sputum
   • dyspnea
   • anorexia
   • impairment of financial capability
5. Knowledge Deficit : about the condition, treatment, prevention relating to :
   • nothing is explained
   • wrong interpretation
   • the information obtained is incomplete / inaccurate
   • lack of knowledge / cognitive.

Nursing Care Plan for Asthma

Nursing Care Plan for Asthma

Asthma is a chronic disease that affects your airways. Your airways are tubes that carry air in and out of your lungs. If you have asthma, the inside walls of your airways become sore and swollen. That makes them very sensitive, and they may react strongly to things that you are allergic to or find irritating. When your airways react, they get narrower and your lungs get less air. This can cause wheezing, coughing, chest tightness and trouble breathing, especially early in the morning or at night.

When your asthma symptoms become worse than usual, it's called an asthma attack. In a severe asthma attack, the airways can close so much that your vital organs do not get enough oxygen. People can die from severe asthma attacks.

Asthma is treated with two kinds of medicines: quick-relief medicines to stop asthma symptoms and long-term control medicines to prevent symptoms.

NIH: National Heart, Lung, and Blood Institute

Nursing Assessment for Asthma

Assessment of nursing in asthma patients, as follows:

Past medical history:

• Assess personal or family history of previous lung disease.
• Assess history of allergic reaction or sensitivity to the substances / environmental factors.
•  Assess patient's employment history.

Activities:

• The inability to perform activities because of difficulty breathing.
• The decline in the ability / improvement needs help doing daily activities.
• Sleep in a sitting position higher.

Respiratory:

• Dipsnea at rest or in response to activity or exercise.
• Breath worsened when the patient lay supine in bed.
• Using the breathing aids drug, for example: raising the shoulders, widen the nose.
• The existence of wheezing breath sounds.
• The recurrent coughing.

Circulation:

• There is an increasing blood pressure.
• There is an increasing frequency of heart.
• The color of skin or mucous membranes normal / gray / cyanosis.
• Flushing or sweating.

Integrity ego:

• Anxiety
• Fear
• Sensitive stimulation
• Fidget

Nutrient intake:

• Inability to eat due to respiratory distress.
• Weight loss due to anorexia.

Social relations:

• The limited physical mobility.
• Hard talk
• The existence of dependence on others.

Sexuality:

• Decrease in libido

Nursing Diagnosis, Nursing Interventions, Nursing Care Plan for Asthma

Impaired Gas Exchange

Related to :

• Altered oxygen supply,
• obstruction of airways by secretions,
• bronchospasm

Nursing Interventions :

• Monitor vital signs
• Monitor and graph serial ABGs and pulse oximetry.
• Administer medications as indicated
• monitor skin and mucous membrane color.

Ineffective Airway Clearance

Related to :

• Bronchospasm,
• Increased production of secretions,
• Retained secretions, thick, viscous secretions

Nursing Interventions :

• Assist client to maintain a comfortable position.
• Evaluate respiratory rate/depth and breath sounds.
• Encourage/instruct in deep-breathing and directed coughing exercises.
• Keep environmental free from sources of allergen such as dust, smoke, and feather pillows to a minimum according to individual situation.

Nursing Care Plans for Fluid Volume Deficit

Definition : Decreased intravascular, interstitial, and or intracellular fluid.

Related Factors:
Active fluid volume loss; failure of regulatory mechanisms

Deficient Fluid volume Characteristics : Decreased urine output, increased urine concentration, weakness, sudden weight loss, decreased venous filling, increased body temperature, decreased pulse volume or pressure, change in mental state, elevated hematocrit, decreased skin or tongue turgor; dry skin/mucous membranes, thirst, increased pulse rate, decreased blood pressure.

Deficient Fluid volume Outcomes

• Maintains urine output more than 1300 ml/day (or at least 30 ml/hr)
• Maintains normal blood pressure, pulse, and body temperature
• Maintains elastic skin turgor; moist tongue and mucous membranes; and orientation to person, place, time
• Explains measures that can be taken to treat or prevent fluid volume loss
• Describes symptoms that indicate the need to consult with health care provider

NOC Outcomes (Nursing Outcomes Classification): Suggested NOC Labels

• Fluid Balance
• Hydration
• Nutritional Status: Food and Fluid Intake

NIC Interventions (Nursing Interventions Classification) Suggested NIC Labels

• Fluid Management
• Hypovolemia Management
• Shock Management: Volume

Nursing Interventions Nursing Care Plans for Fluid Volume Deficit

• Asses:
  
  • Moistness of mucous membrane and skin turgor and chart findings.
  • Intake and output.
  • Orthostatic hypotension QD.
  • Daily weights using same scale.
  • Labs: HCT, BUN, Specific gravity, Sodium
• Encourage fluid intake.


• Assist patient with drinking if necessary.


• Explore patient's understanding of etiological factors and provide necessary teaching.