NCP for Psoriasis - 4 Nursing Diagnosis

NCP for Psoriasis - 4 Nursing Diagnosis

Psoriasis   December 08, 2015

Nursing Care Plan for Psoriasis

Psoriasis is a skin disease whose sufferers experience skin replacement process is too fast. The emergence of this disease sometimes for a longer period. In contrast to the normal human skin changes that usually lasts for three to four weeks, the skin changes in patients with psoriasis take place quickly is about 2-4 days, (it can even happen faster) that a lot of skin cell turnover and thickened.

Psoriasis can be found in all parts of the world with morbidity (incidence rate) is different. In terms of age, Psoriasis can be at any age, but usually more often found in adults.

Psoriasis is a skin disorder characterized by plaque, patches, scaly known papulosquamous disease. (Price, 1994).

The cause of psoriasis is unknown until now. Allegedly inherited polygenic. Although the majority of patients with psoriasis arises spontaneously, but in some patients found the existence of precipitating factors, among others:

1) Trauma
Psoriasis first arise in places that are exposed to trauma, scratching, incision, a former vaccination, and so on. The likelihood that this is a mechanism Koebner phenomenon. Typical in psoriasis arises 7-14 days after trauma.

2) Infection
In children, especially hemolytic streptococcal infections often cause guttate psoriasis. Psoriasis also arise after other bacterial infection and certain viral infections, but disappeared after infection healed.

3) Climate
Some cases tend to heal in the summer, while in the rainy season will recur.

4) Endocrine factors
The highest incidence at puberty and menopause. Psoriasis tends to improve during pregnancy and relapse and resistance to treatment after birth. Sometimes generalized pustular psoriasis arise during pregnancy and after high-dose progesterone treatment.

5) Sunlight
Although sunlight generally useful for patients with psoriasis, but in some patients the strong sunlight can stimulate the onset of psoriasis. Photochemical treatment has similar effects in some patients.

6) Metabolic
Hypocalcemia may cause psoriasis.


Patients usually complain of mild itching in places of predilection, namely the scalp, the border area with the face, extremities on the extensor, especially the elbows and knees, and the lumbosacral region. Skin disorders consisting of patches of elevated erythema (plaque) with scales on it. The scales are layered, rough, and white like mica, and transparent. In psoriasis there is the phenomenon of droplets of wax, Auspitz and Köbner.


Symptoms of psoriasis include:
Complained of mild itching.
Patches of erythema elevated, scaly thereon.
There is a phenomenon of the droplets of wax.
Cause nail abnormalities.


Nursing Diagnosis for Psoriasis

1. Impaired sense of comfort related to disease-related symptoms
characterized by: the itching, burning sensation on the skin, anxiety, clients seemed agitated, and disruption of sleep patterns.

2. Impaired skin integrity related to chemical irritation, mechanical factors, nutritional factors
characterized by: tissue damage of the skin (scaly skin, poor skin turgor, cracks, patches, itching).

3. Disturbed body image related to the biophysical, disease, and perceptual
characterized by: insecure, self-conscious, feelings of isolation, the interaction is reduced.

4. Anxiety related to changes in health status
characterized by: a client anxiety, fear, sleep disturbances, often sweating.

Fluid and Electrolyte Imbalances related to Chronic Kidney Disease (CKD)

Fluid and Electrolyte Imbalances related to Chronic Kidney Disease (CKD)

Nursing Care Plan   November 18, 2013

Nursing Care Plan for Chronic Kidney Disease / Chronic Renal Failure

Definition

Chronic renal failure is usually the end result of loss of renal function gradually (Doenges, 1999; 626)

Chronic kidney failure occurs when the kidneys are not able to maintain an internal environment that is consistent with the life and recovery of function is not started. In most healthy individuals transition from status to chronic or persistent disease is very slow and wait a few years. (Barbara C. Long, 1996; 368)

Chronic renal failure or end stage renal disease (ESRD) is a progressive renal dysfunction and irreversible where the body's ability to maintain metabolism and failed fluid and electrolyte balance, causing uremia (urea retention and other nitrogen waste in the blood). (Brunner & Suddarth, 2001; 1448)

Chronic renal failure is a progressive development of renal failure and slow, usually lasts several years. (Price, 1992; 812)


Causes 

Causes of CRF according to Price, 1992; 817, divided into eight classes, among others:

1. Infections such as chronic pyelonephritis.
2. Inflammatory diseases such as glomerulonephritis.
3. Hypertensive vascular disease, such as benign nephrosclerosis, malignant nephrosclerosis, renal artery stenosis.
4. Connective tissue disorders such as systemic lupus erythematosus, polyarteritis nodosa, progressive systemic sclerosis
5. Congenital and hereditary disorders such as polycystic kidney disease, renal tubular acidosis.
6. Metabolic diseases such as: diabetes, gout, hyperparathyroidism, amyloidosis.
7. Toxic nephropathy, eg analgesic abuse, lead nephropathy.
8. Obstructive nephropathy, for example:

• Upper urinary tract: calculi neoplasm, fibrosis netroperitoneal.
• Lower urinary tract: prostatic hypertrophy, urethral stricture, congenital anomalies of the neck of the bladder and urethra.

Nursing Diagnosis for Chronic Kidney Disease (CKD) : Fluid and Electrolyte Imbalances related to edema, secondary : the liquid volume is not balanced, and therefore retention of Na and H2O

Goal :
Maintaining an ideal body weight without excess fluid

Outcomes:
no edema,
balance between input and output


Intervention:
1. Assess fluid status by measuring body weight per day, the balance of input and output, skin turgor vital signs

2. Limit fluid intake
R /: fluid restriction will determine ideal body weight, urine output, and response to therapy.

3. Explain to patients and families about the liquid restrictions.
R /: Understanding increase patient cooperation and families in the fluid restriction.

4. Instruct patient / teach the patient to record the use of fluids, especially income and output.
R /: To find out the balance of inputs and outputs.


Nursing Care Plan for Chronic Renal Failure - CRF

Nursing Diagnosis and Nursing Intervention for CRF - Chronic Renal Failure

Decreased Cardiac Output - Ventricular Septal Defect Care Plan

Decreased Cardiac Output - Ventricular Septal Defect Care Plan

Ventricular Septal Defect   November 07, 2013

Ventricular Septal Defect

A ventricular septal defect (VSD) is a defect in the ventricular septum, the wall dividing the left and right ventricles of the heart.

A ventricular septal defect happens during pregnancy if the wall that forms between the two ventricles does not fully develop, leaving a hole. A ventricular septal defect is one type of congenital heart defect. Congenital means present at birth.

Decreased Cardiac output Definition

Inadequate blood pumped by the heart to meet metabolic demands of the body



Nursing Diagnosis : Decreased cardiac Output related to cardiac malformations.

Goal:

• Decreased cardiac output does not occur

Interventions:

1. Observation quality and strength of heart rate, peripheral pulses, skin color and warmth
2. Enforce the degree of cyanosis (eg, mucous membrane color degrees of finger)
3. Give digitalis medications appropriate order.
4. Give diuretic medications appropriate order.

Rationale:

1. Provide data for the evaluation of interventions and enable early detection of complications.
2. Determine the development of the client's condition and determine appropriate interventions.
3. Digitalis drugs that strengthen the heart muscle contractility increases cardiac output / clients at least able to adapt to the situation.
4. Reduce excess fluid in the body pile so the heart will be lighter.

NANDA Decreased Cardiac Output

Acute Pain - Nursing Care Plan for Hypertensive Heart Disease

Acute Pain - Nursing Care Plan for Hypertensive Heart Disease

Nursing Care Plan   November 07, 2013

Hypertensive Heart Disease

Hypertensive heart disease includes a number of complications of systemic arterial hypertension or high blood pressure that affect the heart.

Symptoms of heart failure include:

• Shortness of breath
• Swelling in the feet, ankles, or abdomen
• Difficulty sleeping flat in bed
• Bloating
• Irregular pulse
• Nausea
• Fatigue
• Greater need to urinate at night

Symptoms of ischemic heart disease may include:

• Chest pain which may radiate (travel) to the arms, back, neck, or jaw
• Chest pain with nausea, sweating, shortness of breath, and dizziness; these associated symptoms may also occur without chest pain
• Irregular pulse
• Fatigue and weakness

Acute Pain Definition

Pain is whatever the experiencing person says it is, existing whenever the person says it does (McCaffery, 1968); an unpleasant sensory and emotional experience arising from actual or potential tissue damage or described in terms of such damage (International Association for the Study of Pain) sudden or slow onset of any intensity from mild to severe with an anticipated or predictable end and a duration of  less than 6 months.



Nursing Care Plan for Hypertensive Heart Disease

Acute Pain (headache) related to increased cerebral vascular pressure.


Goal :

• Client reported pain / discomfort disappeared / controlled .

Interventions and Rationale :

1. Maintain bed rest during the acute phase.

2. Give non-pharmacological measures to eliminate headaches eg, a cold compress on the forehead, back and neck massage, quiet, dim the room lights room lights, relaxation techniques (manual imagination, disktraksi) and leisure time activities.

3. Eliminate / minimize vasoconstriction activity that can increase headache eg, straining during defecation, coughing and bending length.

4. Assist patients in ambulation as needed.

5. Give liquids, soft foods, regular oral care in the event of bleeding nose or nasal pack has been done to stop the bleeding.

Rationale:

1. Minimize stimulation / promote relaxation.

2. Actions that reduce cerebral vascular pressure and the slow / block sympathetic response is effective in relieving headaches and complications.

3. Activities that increase vasoconstriction causing headaches in an increase in cerebral vascular pressure.

4. Dizziness and blurred vision often associated with pain kepala.pasien can also experience episodes of postural hypotension.

5. Increase the general comfort, compress the nose can interfere with swallowing or breathing requires mouth, causing stagnation oral secretions and mucous membranes dry out.

Physical Examination for Congestive Heart Failure (CHF)

Nursing Care Plan for Congestive Heart Failure - CHF

Impaired Physical Mobility - NCP for Guillain-Barre Syndrome

Impaired Physical Mobility - NCP for Guillain-Barre Syndrome

Nursing Care Plan   October 30, 2013

Nursing Care Plan for Guillain-Barre Syndrome

Guillain-Barre syndrome or GBS is a severe inflammatory disorder of the peripheral nerves.

Guillain-Barre Syndrome is an inflammatory disorder in which the body's immune system attacks the nerves, causing severe weakness and numbness and eventually leading to muscular paralysis.

The symptoms of Guillain-Barre syndrome are lack of feeling, weakness or itchiness in arms or legs, and possible loss of feeling and movement in the upper body, face, arms and legs. The symptoms can remain in this phase and can cause little difficulty in walking. However, in some cases the illness can progress resulting in entire paralysis of arms and legs.

Nursing Diagnosis: Impaired Physical Mobility related to neuromuscular damage

Goals:
To maintain the position of function with no complications (contractures, pressure sores).

Outcomes:
Clients can improve the strength and function of the affected part

Nursing Interventions and Rationale:
1. Assess motor strength / functional ability by using a scale of 0-5.
R / Define the development / re-emergence of signs that hinder the achievement of goals / expectations of the patient.

2. Give the patient a position that causes a sense of comfort. Make changes to the position on a regular schedule as needed on an individual basis.
R / Reduce fatigue, increase relaxation. Reduce the risk of ischemia / damage to the skin.

3. Chock extremities and joints with a pillow.
R / Maintain extremity in a physiological position, prevent contractures.

4. Perform passive range of motion exercises. Avoid active exercise during the acute phase.
R / Stimulates circulation, improve muscle tone and increase joint mobilization.

5. Coordinate care provided and the period of uninterrupted rest.
R / Excessive use of muscles can increase the time it takes to remielinisasi, arena may extend the time for healing.

6. Encourage you to do the exercise that continues to be developed and depend on individual tolerance.
R / exercise activities in the affected areas gradually improved / fixed, improve organ function normally and have a positive psychological effect

7. Give lubrication / oil artificially within their needs.
R / Prevent from drying the client's body.

Collaboration

1. Confirm with / refer gets physical therapy / occupational therapy.
R / Helpful in creating individual muscle strength / exercise conditioned and running training programs and identify tools to maintain the mobilization and independence in performing daily activities.

Disturbed Body Image - Nursing Care Plan for Brain Tumor

Disturbed Body Image - Nursing Care Plan for Brain Tumor

Nursing Care Plan   October 29, 2013

A brain tumor is an intracranial solid neoplasm, a tumor within the brain or the central spinal canal.

The most common primary brain tumors are:

• Gliomas (50.4%)
• Meningiomas (20.8%)
• Pituitary adenomas (15%)
• Nerve sheath tumors (8%)

The most frequent symptoms of brain tumors include:

• Headaches that tend to be worse in the morning and ease during the day
• Seizures or convulsions
• Nausea or vomiting
• Weakness or loss of feeling in the arms or legs
• Stumbling or lack of coordination in walking
• Abnormal eye movements or changes in vision
• Drowsiness
• Changes in personality or memory
• Changes in speech

Nursing Care Plan for Brain Tumor

Nursing Diagnosis : Disturbed Body Image related to hair loss, and changes in the structure and function of the body.

Goal:

• Patients express a positive self-image with the criteria of patients receiving changes to body image.

Interventions:

1. Assess the patient's reaction to body changes.
2. Observation of patient social interaction.
3. Maintain a therapeutic relationship with the patient.
4. Instruct the patient to open communication with health care or other important person.
5. Help patients find effective coping about body image.

Rational:

1. Determine the patient's reaction to changes in body image.
2. Social withdrawal may occur due to rejection.
3. Facilitate a therapeutic relationship that is open.
4. Expression of fears openly to reduce anxiety.
5. Help patients find coping strategies that can reduce anxiety and fear.