4 Nursing Diagnosis for Gonorrhea with Interventions

Nursing Care Plan for Gonorrhea

Nursing Diagnosis for Gonorrhea

Gonorrhea is a sexually transmitted disease (STD) caused by bacteria called Neisseria gonorrhoeae. The bacteria can be passed from one person to another through vaginal, oral, or anal sex, even when the person who is infected has no symptoms. It can also be passed from a mother to her baby during birth. You cannot catch gonorrhea from a towel, a doorknob, or a toilet seat.

Gonorrhea does not always cause symptoms, especially in women. In men, gonorrhea can cause pain when urinating and discharge from the penis. If untreated, it can cause epididymitis, which affects the testicles and can lead to infertility. In women, gonorrhea can cause bleeding between periods, pain when urinating and increased discharge from the vagina. If untreated, it can lead to pelvic inflammatory disease, which causes problems with pregnancy and infertility. Gonorrhea can pass from mother to baby during pregnancy.

Gonorrhea symptoms in women
  • Greenish yellow or whitish discharge from the vagina
  • Lower abdominal or pelvic pain
  • Burning when urinating
  • Conjunctivitis (red, itchy eyes)
  • Bleeding between periods
  • Spotting after intercourse
  • Swelling of the vulva (vulvitis)
  • Burning in the throat (due to oral sex)
  • Swollen glands in the throat (due to oral sex)

Gonorrhea symptoms in men
  • Greenish yellow or whitish discharge from the penis
  • Burning when urinating
  • Burning in the throat (due to oral sex)
  • Painful or swollen testicles
  • Swollen glands in the throat (due to oral sex)

Nursing Diagnosis for Gonorrhea 1.

Acute Pain related to the reaction of infection

After nursing actions, the client will:
  • Identifying the causes
  • Using the methods of prevention of non-analgesic to relieve pain
  • Using analgesics as needed
  • Reported pain was controlled

Nursing Interventions: Acute Pain - Nursing Care Plan for Gonorrhea:
  1. Examine in a comprehensive pain include location, characteristics, and onset, duration, frequency, quality, intensity / severity of pain, and precipitation factors.
  2. Observation of non-verbal cues of discomfort, especially the inability to communicate effectively.
  3. Use therapeutic communication so that the client can express pain.
  4. Provide support to clients and families
  5. Control of environmental factors that can affect the client's response to discomfort (ex.: room temperature, irradiation, etc.)
  6. Teach the use of non-pharmacologic techniques (ex.: relaxation, guided imagery, music therapy, distraction, application of heat and cold, massage, hypnosis, therapeutic activity)
  7. Give analgesics as ordered
  8. Increase enough sleep or rest
  9. Evaluate the effectiveness of the measures that have been used to control pain.

Nursing Diagnosis for Gonorrhea 2.

Hyperthermia related to inflammatory reactions

After nursing actions, the client will:
  • The temperature in the normal range
  • Pulse and respiration within the normal range
  • No skin discoloration and no headache

Nursing Interventions: Hyperthermia - Nursing Care Pla for Gonorrhea
  • Monitor vital sign
  • Monitor the temperature at least 2 hours
  • Monitor skin color.
  • Increase fluid intake and nutrition
  • Cover the client to prevent loss of body heat
  • Compress clients in the groin and axilla
  • Give antipyretics as needed.

Nursing Diagnosis for Gonorrhea 3.

Impaired Urinary Elimination related to the inflammatory process

After nursing actions, the client will:
  • Elimination of urine would not be disturbed: the smell, the number, color of urine within expected ranges and urine output without pain

Nursing Interventions: Impaired Urinary Elimination - Nursing Care Pla for Gonorrhea
  1. Monitor urine elimination include: frequency, consistency, odor, volume, and color appropriately
  2. Refer to urologist if the cause of acute discovered.

Nursing Diagnosis for Gonorrhea 4.

Anxiety related to the disease

After nursing actions, the client will:
  • No signs of anxiety
  • Reported a decrease in the duration and episodes of anxiety
  • Reporting needs adequate sleep
  • Demonstrate flexibility role

Nursing Interventions: Anxiety - Nursing Care Pla for Gonorrhea
  1. Assess the level of anxiety and physical reactions to high levels of anxiety (tachycardia, tachypnea, non-verbal expressions of anxiety)
  2. Accompany clients to support the anxiety and fear
  3. Instruct client to use relaxation techniques
  4. Give medication to reduce anxiety in a proper way
  5. Provide current information on the diagnosis, treatment, and prognosis

History of Self Care Deficit Theory - Dorothea Elizabeth Orem

Self Care Deficit Theory - Dorothea Elizabeth Orem

Dorothe Orem was born in Baltimore, Maryland in 1914. Dorothe Orem attended Seton High School in Baltimore, and graduated in 1931. She received a diploma from the Providence Hospital School of Nursing in Washington, D.C. in 1934 and went on to the Catholic University of America to earn a B.S. in Nursing Education in 1939, and an M.S. in Nursing Education in 1945.

Dorothea Orem was a nursing theorist and creator of the self-care deficit nursing theory, also known as the Orem model of nursing.

She studied Diploma in Nursing in early 1930’s at the Providence Hospital School og Nursing In Washington D.C.,

In 139 and 1945 she finished B.S. Nursing Education ( BSN Ed.) and MSN Ed successively in Catholic University of America, Washington D.C.

1976 She become Honorary Doctorates: Doctors of Science from Georgetown University and Incarnate word college in San Antonio in Texas in 1980.

In 1988 she finished Doctor of Humane Letters from Illinois Wesleyan University in Bloomington, Illinois.
1988 She Graduated from University of Missouri in Columbia, Doctor Honoris Causae.

In 1971 Orem published Nursing: Concepts of Practice, the work in which she outlines her theory of nursing, the Self-care Deficit Theory of Nursing. The success of this work and the theory it presents established Orem as a leading theorist of nursing practice and education.

A Glimpse of Orem’s Accomplishments and Contributions:
  • Dorothea Orem as a member of a curriculum subcommittee at Catholic University recognized the need to continue in developing a conceptualization of nursing.
  • Orem’s Nursing: Concept of Practice was first published in 1971 and subsequently in 1980, 1985, 1991, 1995, and 2001.
  • Nursing: Concepts of Practice was the original publication of the conceptual framework (Orem, 1971)
  • 1949-1957 Orem worked for the Division of Hospital and Institutional Services of the Indiana State Board of Health. Her objective was to improve the quality of nursing in general hospitals and she was able develop the definition of nursing by this time
  • 1958-1960 she help publish "Guidelines for Developing Curricula for the Education of Practical Nurses" in 1959.
  • Washington D.C. in 1957, Orem further developed her ideas, first as a consultant in the Office of Education where her task was to improve the nursing component of a vocational nursing curriculum.
  • Orem’s ideas were further formalized after her participation in the Nursing Development Conference Group (NDCG), the two were committed to the development of structured nursing knowledge and to nursing as a practice discipline” (Hartweg, 1995)
  • Continues to develop her theory after her retirement in 1984
  • Dr. Orem continues to be active in theory development. She completed the 6th edition of Nursing: Concepts of Practice, published by Mosby in January 2001.

  • Self-care: which is the practice of activities that an individual initiates and performs on his or her own behalf to maintain life, health, and well-being.
  • Self-care agency: which is a human ability that is "the ability for engaging in self-care," conditioned by age, developmental state, life experience, socio-cultural orientation, health, and available resources.
  • Therapeutic self-care demand: which is the total self-care actions to be performed over a specific duration to meet self-care requisites by using valid methods and related sets of operations and actions.
  • Self-care requisites: which include the categories of universal, developmental, and health deviation self-care requisites.


1. Universal self care requisites

Associated with life processes and the maintenance of the integrity of human structure and functioning
Common to all , ADL
Identifies these requisites as:
  • Maintenance of sufficient intake of air ,water, food
  • Provision of care assoc with elimination process
  • Balance between activity and rest, between solitude and social interaction
  • Prevention of hazards to human life well being and
  • Promotion of human functioning

2. Developmental self care requisites

Associated with developmental processes/ derived from a condition…. Or associated with an event
  • E.g. adjusting to a new job
  • adjusting to body changes

3. Health deviation self care

Required in conditions of illness, injury, or disease .these include:--
Seeking and securing appropriate medical assistance
Being aware of and attending to the effects and results of pathologic conditions
Effectively carrying out medically prescribed measures
Modifying self concepts in accepting oneself as being in a particular state of health and in specific forms of health care
Learning to live with effects of pathologic conditions

Nanda - 7 Nursing Diagnosis for Preeclampsia

Nanda Nursing Diagnosis for Preeclampsia

Preeclampsia/eclampsia is a complex hypertensive disorder of pregnancy affecting multiple systems. Preeclampsia is a condition that pregnant women can get. Preeclampsia and eclampsia are complications of pregnancy. In preeclampsia, the woman has dangerously high blood pressure, swelling, and protein in the urine.

Symptoms of Preeclampsia

The condition is said to be usually discovered after a woman’s 20 weeks into pregnancy. However, preeclampsia is noted to continually but gradually develop throughout the woman’s pregnancy period. The symptoms of this condition may include but should not be limited to the following:

1) Excessive protein present in the urine
2) Minimized urine output
3) High blood pressure
4) Blurred and oversensitivity to light vision
5) Unbearable headaches
5) Sudden weight gain
6) Vomiting and nausea

Treatment and Prevention of Preeclampsia

As mentioned earlier in the article, the only possible way to get rid of the condition is to have the baby delivered although the doctor may recommend other possible treatments when delivery of the baby is still too early and obviously will pose more harm than good both to the mother and the unborn child. In this case, some medication may be advised for the mother to take and follow to help lower her blood pressure. The doctor will also most likely recommend a complete bed rest for the pregnant woman.

In the even that delivery of the baby is recommended and possible, the doctor will intravenously give the pregnant woman magnesium sulfate to prevent seizures and induce an increased blood flow during the delivery. Within weeks after the delivery, the woman’s blood pressure should go back to its normal rate and should therefore cause no additional worry health wise.

With the cause of the disorder still being in discussion and research, there too has been no known way as to its prevention. However, the constant and regular intake of vitamin D is highly recommended by doctors as it lowers the risk for a women to acquire preeclampsia during her pregnancy period.

7 Nursing Diagnosis for Preeclampsia

1. Acute pain
reated to post Caesarean section incision

2. Alteration in Bowel Elimination: Constipation
related to decreased intestinal peristalsis.

3. Risk for infection
related to tissue trauma / skin damage

4. Risk for Fluid Volume Deficit
related to the bleeding

5. Altered family processes
related to the preparation of infant acceptance.

6. Sleep pattern disturbance
related to the tension during the birth process, pain.

7. Knowledge Deficit: perawtan about babies, family planning, nutrition
related to inadequate information.

Nursing Care Plan for Low Back Pain - 5 Nanda Diagnosis

 5 Nanda Diagnosis for Low Back Pain

Low Back Pain a disorder occurring at the backbone generally suffered by the Geriatric. Although that, it can also be suffered by adult.

Low Back Pain or pain in lumbar region affects nearly 80% of people once or many times in their lives. It is a pain caused due to musculoskeletal disorder and can cause acute, sub-acute or chronic pain. It is the area that supports most of the body weight of a human body, this structure makes all the movements of the body possible and provides flexibility to the body.

Causes of Low Back Pain

1. Too long sitting. Job or activity, such as: scientist, editors, drivers or office workers who requires sitting in a long time, is one of cause of back pain.

2. Wrong sitting position. Wrong sitting or non-ergonomic chairs will trigger pain. It is because the backbone, tendon tissue and muscle are too much forced to keep the upper body. It will cause fatigue in the muscle tissue, especially the back of the lumbar muscles.

3. Wrong position when lifting a heavy load will cause stress on back muscles. It is not infrequently occurring if our hips are suddenly shocked and feeling this pain immediately.

4. Worse backbone structures. It can be caused by nature from birth or due to pregnancy. Spine would be pulled to the front due to excess weight infants in a pregnant woman. After birth, this condition will return to the normal condition. In other circumstances, pain can also arise due to the influence of the other sick organs such as: kidneys.

5 Nursing Diagnosis  for Low Back Pain - Nanda

1. Acute Pain
related to musculoskeletal problems.

2. Impaired physical mobility
related to pain, muscle spasm, and reduced flexibility.

3. Knowledge Deficit
related to body mechanics techniques to protect the back.

4. Ineffective Role Performance
related to impaired mobility and chronic pain.

5. Imbalanced Nutrition: More Than Body Requirements
related to obesity.

Nursing Diagnosis Impaired Physical Mobility - Rheumatoid Arthritis

Nursing Care Plan for Rheumatoid Arthritis

Nursing Diagnosis for Rheumatoid Arthritis

Rheumatoid arthritis (RA) is an inflammatory disease that causes pain, swelling, stiffness, and loss of function in the joints. It occurs when the immune system, which normally defends the body from invading organisms, turns its attack against the membrane lining the joints.

Diagnosis of rheumatoid arthritis (RA) – For a long time there was no specific test that would unambiguously confirm the presence of the disease . Currently, diagnosis of disease based on biochemical analysis of blood, changes in the joints are visible on x-rays, and the use of basic clinical markers, but also in conjunction with the general clinical manifestations – fever, malaise, and weight loss

In the analysis of blood examined ESR, rheumatoid factor, platelet count, etc. The most advanced analysis is the titer of antibodies to cyclic citrulline-containing peptides – ACCP, anti-CCP, anti-CCP. The specificity of this indicator is 90%, while it is present in 79% of sera from patients with RA.

Diagnostically important clinical features are the lack of discoloration of the skin over the inflamed joints, the development of tenosynovitis flexors or extensors of the fingers and the formation of amyotrophy, typical strains of brushes, so-called "rheumatoid wrist.

Nursing Diagnosis for Rheumatoid Arthritis: Impaired Physical Mobility
related to:

Can be evidenced by:
  • Reluctance to try moving / inability to move in with their own physical environment.
  • Limiting the range of motion, coordination imbalances, decreased muscle strength / control and mass (advanced stage).

The expected outcomes / evaluation criteria, patients will:
  • Maintaining a function of position in the absence / restrictions contractures.
  • Maintain or improve strength and function of and / or compensation of the body.
  • Demonstrate techniques / behaviors enabling activities.

Nursing Interventions : Impaired Physical Mobility - Rheumatoid Arthritis

1. Keep the rest bed rest / activity schedule to sit if necessary to provide a continuous period and nighttime sleep uninterrupted.
Rationale: Systemic Rest is recommended during acute exacerbations, and all phases of the disease is important to prevent exhaustion maintain strength

2. Evaluation / continue monitoring the level of inflammation / pain in the joints.
Rationale: The level of activity / exercise depends on the development / resolution of inflammation peoses

3. Change positions frequently with sufficient amount of personnel. Demonstrate / aids removal techniques and the use of mobility assistance.
Rationale: Eliminates stress on the network and improves circulation. Memepermudah patient self-care and independence. Proper removal techniques to prevent tearing skin abrasion.

4. Assist with range of motion active / passive, and resistive exercise also demikiqan isometris if possible.
Rationale: Maintain / improve joint function, muscle strength and general stamina.

5. Position with pillows, sand bags.
Rationale: Increase stability (reducing the risk of injury) and required memerptahankan joint position and body alignment, reducing contractor

6. Encourage the patient to maintain an upright posture and sitting height, standing, and walking.
Rationale: To maximize joint function and maintain mobility.

7. Provide a safe environment, such as raising the chair, using the toilet railings, wheelchair use.
Rationale: Avoiding injury due to accidents / falls

8. Use a small pillow / thin below the neck.
Rationale: Preventing neck flexion.

9. Collaboration: consul with physiotherapy.
Rationale: Useful in formulating training programs / activities based on individual needs and identifying tools.

10. Collaboration: Provide foam mat / converter pressure.
Rationale: Reducing pressure on fragile networks to reduce the risk of immobility.

11. Collaboration: give medications as indicated (steroids).
System may be needed to suppress acute inflammation.

Nursing Management of Rheumatoid Arthritis

Nursing Management of Rheumatoid Arthritis
Nursing Management of Rheumatoid Arthritis

Because the exact cause of rheumatoid arthritis is unknown, there is no causative treatment that can cure this disease. It should really be explained to the patient so that the treatment given out aimed at reducing complaints / symptoms slow the progression of the disease.

The main purpose of the Nursing Management of Rheumatoid Arthritis program is as follows:
  • To relieve pain and inflammation.
  • To maintain joint function and a maximum capacity of patients.
  • To prevent and or correct deformity that occurs in the joints.
  • Maintaining independence so as not to depend on others.
There are a number of ways management, to achieve the goals mentioned above, namely:

1. Education
The first step in the management of this program is to provide adequate education about the disease to patients, their families and anyone connected with patients. Education provided include; understanding, pathophysiology, causes and management of all program components including complex drug regimens, aid resources to overcome the disease and effective method of management provided by the health care team. The education process should be carried out continuously.

2. Rest / sleep
It is important because rheumatoid arthritis is usually accompanied by severe fatigue. Although fatigue can arise every day, but there was a time when people feel better or heavier. Patients should divide their time a day, became, a few times while on the move, followed by a period of rest.

3. Physical Exercise and thermotherapy
Specific exercises can be beneficial in maintaining joint function. This exercise includes active and passive movements at all joints pain, at least twice a day. Medication for pain relief should be given before starting the exercise. Giving a warm compress on the sore and swollen joints may reduce pain. Paraffin bath with adjustable temperature and bath with hot and cold temperatures can be done at home. Exercise and thermotherapy is best regulated by the health workers who have received special training, such as a physical therapist or occupational therapist. Excessive exercise can damage the supporting structure of the joints that are already weakened by a disease.

4. Diet / Nutrition
Rheumatic Patients do not require a special diet. There is a way of giving a diet with a variety of all sorts, but it's all unsubstantiated. The general principle to obtain a balanced diet is important.

5. Drugs
Medications are an important part of the whole program rheumatic disease management. The drugs are used to reduce pain, relieve inflammation and to try to change the course of the disease.

Impaired Gas Exchange related to Pulmonary Tuberculosis

Impaired Gas Exchange related to Pulmonary Tuberculosis

Nursing Diagnosis for Pulmonary Tuberculosis

Pulmonary Tuberculosis is a contagious bacterial infection that involves the lungs, but may spread to other organs.

TB is contracted when someone who has TB and is not receiving the proper treatment of coughs sneezes or spits into the water. This releases the germ into the air thus making it possible for someone else to Inhale it. Therefore Easily TB spreads in poor, overcrowded areas.

A course of TB medication must be taken once every day for 6 months. This course of medication is only taken by individuals who have contracted the disease for the first time. If the course of TB medication is not completed then it is highly Likely that the individual will again contracted TB. However instead of a 6 month course of TB medication the individual will have to have to take TB medication for 8 months or longer.

Nursing Diagnosis for Pulmonary Tuberculosis: Impaired Gas Exchange
related to:
damage to the alveolar-capillary membrane.

Goal: effective gas exchange.

Expected outcomes:
  • Demonstrated effective respiratory frequency.
  • Improved gas exchange in the lung.
  • Adaptive address causative factors.

Nursing Interventions: Impaired Gas Exchange for Pulmonary Tuberculosis

1. Provide a comfortable position, usually with the head of the bed elevated. Return to the affected side. Encourage clients to sit as much as possible.
Rationale: Increasing maximal inspiration, enhance lung expansion and ventilation on the side that does not hurt.

2. Observation of respiratory function, record the frequency of breathing, dyspnea or changes in vital signs.
Rationale: Respiratory Distress and changes in vital signs may occur as a result of physiological stress and pain can indicate the occurrence syock or in connection with hypoxia.

3. Explain to the client that it was carried out to ensure safety.
Rationale: Knowledge of what is expected to reduce anxiety and develop the client's adherence to the treatment plan.

4. Explain to the client about the etiology / precipitating factors or the presence of congested lungs collapse.
Rationale: Knowledge of what is expected to develop the client's adherence to the treatment plan.

5. Keep calm behavior, help the patient to self-control circuitry using breathing more slowly and deeply.
Rationale: Helps clients experiencing physiological effects of hypoxia, which can manifest as fear / anxiety.

6. Collaboration with other health team:
By physicians, radiology and physiotherapy.
Giving antibiotics.
Examination of sputum culture.
Consul thorax X-ray.
Rationale: Evaluating client improvement of lung development.

Ineffective Airway Clearance related to Pulmonary Tuberculosis

Nursing Diagnosis Ineffective Airway Clearance related to Pulmonary Tuberculosis
Nursing Care Plan for Pulmonary Tuberculosis

Pulmonary Tuberculosis (TB) is a contagious bacterial infection that involves the lungs, but may spread to other organs.

The primary stage of TB Usually does not cause symptoms. When symptoms of pulmonary TB occur, they may include:
  • Cough (usually cough up mucus)
  • Coughing up blood
  • Excessive sweating, especially at night
  • Fatigue
  • Fever
  • Unintentional weight loss

Other symptoms that may occur with this disease:
  • Breathing difficulty
  • Chest pain
  • Wheezing

Nursing Diagnosis for Pulmonary Tuberculosis: Ineffective Airway Clearance
related to: the viscous secretions / blood.

Goal: Cleanliness effective airway.

Expected outcomes:
  • Clients no additional breathing.
  • Clients find a comfortable position that allows increased air exchange when indicated.
  • Clients drink lots (1500 - 2000 cc) to reduce the viscosity of secretions.

Nursing Interventions: Ineffective Airway Clearance relate to Pulmonary Tuberculosis

1. Teach the client about the proper method of controlling cough.
Rationale: Coughing hard causes bleeding in the pulmonary veins.

2. Perform diaphragmatic breathing.
Rationale: Respiratory diaphragm lower respiratory rate and increased alveolar ventilation.

3. Auscultation of the lungs before and after coughing.
Rationale: This helps evaluate the effectiveness of cough effort.

4. Teach client action to reduce the viscosity of secretions: maintain adequate hydration; increase fluid intake 1000 to 1500 cc / day if not contraindicated.
Rational: Secretion difficult to dilute thick and can cause blockage of mucus, which leads to atelectasis.

5. Encourage or provide good oral care after coughing.
Rationale: good oral Hiegene increase sense of well being and prevent bad breath.

6. Explain to the client and the family to comply with the advice of the doctors and nurses: as avoiding foods that cause coughing, as well as odors.
Rationale: With clear information clients are expected to work together in providing therapy.

7. Collaboration with other health team:
By physicians, radiology and physiotherapy.
Giving drugs
Tredelenbeg position (head down)
Rationale: Evaluating client improvement of bleeding clients of cough blood.

Imbalanced Nutrition, Less Than Body Requirements related to Pleural Effusion

Imbalanced Nutrition, Less Than Body Requirements related to Pleural Effusion
Nursing Care Plan for Pleural Eeffusion

Nursing Diagnosis: Imbalanced Nutrition, Less Than Body Requirements

related to:
  • increased metabolism,
  • loss of appetite due to shortness of breath.

Goal: The nutritional requirements are met.

Expected outcomes:
  • Consumption of more than 40% of the amount of food,
  • normal weight,
  • lab results within normal limits.

Nursing Interventions: Imbalanced Nutrition, Less Than Body Requirements for Pleural Effusion

1. Motivate the importance of nutrition.
Rationale: Eating habits are influenced by a person's tastes, habits, religion, economics and knowledge about the importance of nutrition for the body.

2. Auscultation bowel sounds.
Rational: Bowel sounds are decreased or increased indicates a disturbance in digestive function.

3. Perform oral hygiene every day.
Rational: Bad breath odor can reduce appetite.

4. Serve food as attractive as possible.
Rational: Presenting interesting food can increase appetite.

5. Give small amounts of food often.
Rational: The food in small portions do not need energy, lots of easy distraction reflex.

6. Collaboration with a team of nutrition, the provision of a diet high in calories and high in protein.
Rationale: A diet high in calories and high in protein is very good for metabolic needs and antibody formation.

7. Collaboration with doctors, or consulting for laboratory examination alabumin and vitamin and nutritional supplements, if dietary intake continues to decline over 30% of the requirement.
Rationale: Increasing intake of protein, vitamins and minerals can increase the fatty acids in the body.

Ineffective Breathing Pattern related to Pleural Effusion

Nursing Care Plan for Pleural Effusion

Nursing Diagnosis for Pleural Effusion : Ineffective Breathing Pattern

related to:
decreased lung expansion secondary to accumulation of fluid in the pleural cavity.

Goal: Patient is able to maintain normal lung function.

Expected outcomes : rhythm, frequency and depth of breathing in the normal range, the chest X-ray examination did not reveal any accumulation of fluid, audible breath sounds.

Nursing Interventions Ineffective Breathing Pattern for Pleural Effusion:

1. Identification of the causative factors.
Rationale: By identifying the causes, we can determine the type of pleural effusion so it can take appropriate action.

2. Assess the quality, frequency and depth of breathing, report any changes that occur.
Rationale: By reviewing the quality, frequency and depth of breathing, we can determine the extent of changes in the patient's condition.

3. Give the patient in a comfortable position, in a sitting position, with the head of the bed elevated 60-90 degrees.
Rationale: Decreased diaphragm expands the chest area so it can be a maximum lung expansion.

4. Observation vital signs (temperature, pulse, blood pressure, respiration and patient response).
Rationale: Increased respiration and tachycardia is an indication of a decline in lung function.

5. Perform auscultation breath sounds every 2-4 hours.
Rational: Auscultation of breath sounds to determine abnormalities in the lungs.

6. Help and teach the patient to cough and breath in an effective manner.
Rational: Hitting the area of pain when coughing or breathing deeply. Emphasis chest muscles and abdomen made ​​more effective cough.

7. Collaboration with the medical team for the delivery of oxygen and other drugs and thorax photo.
Rationale: Provision of oxygen can reduce the burden of respiratory and prevent cyanosis due hipoxia. Thorax with a photo of the progress can be monitored and the liquid reduced pulmonary return of power development.

Ineffective Breathing Pattern related to Cardiac Tamponade

Nursing Care Plan for Cardiac Tamponade

Nursing Diagnosis and Interventions for Cardiac Tamponade : Ineffective Breathing Pattern

Cardiac tamponade is pressure on the heart that occurs when blood or fluid builds up in the space between the heart muscle (myocardium) and the outer covering sac of the heart (pericardium).

  • Anxiety, restlessness
  • Chest pain
    • Radiating to the neck, shoulder, back, or abdomen
    • Sharp, stabbing
    • Worsened by deep breathing or coughing
  • Difficulty breathing
  • Discomfort, sometimes relieved by sitting upright or leaning forward
  • Fainting, light-headedness
  • Pale, gray, or blue skin
  • Palpitations
  • Rapid breathing
  • Swelling of the abdomen or other areas
Other symptoms that may occur with this disorder:
  • Dizziness
  • Drowsiness
  • Weak or absent pulse

Nursing Diagnosis for Cardiac Tamponade : Ineffective Breathing Pattern
related to: hyperventilation
characterized by: tachypnea, signs kussmaul breathing.

Goal: Patterns breath back effectively.
the expected outcomes:
  • Tachypnea no
  • Signs kussmaul no
  • Vital signs are within normal ranges (RR: 16-20 X / min).

Nursing Interventions: Ineffective Breathing Pattern - Nursing Care Plan for Cardiac Tamponade

  1. Monitor strictly vital signs, especially respiratory frequency. Rationale: Changes in breathing patterns can affect vital signs.
  2. Monitor the contents breathing, chest expansion, regularity of breathing, mouth breathing and muscle use a respirator. Rationale: The development of the chest and use accessory muscles indicate breathing pattern disorders.
  3. Give the semi-Fowler position if not contraindicated. Rationale: Facilitates lung expansion
  4. Teach clients a deep breath. Rationale: With the deep breathing exercise can increase oxygen intake.

Collaboration :
  1. Give oxygen as indicated. Rationale: Oxygen adequate to avoid the risk of tissue damage.
  2. Give medication as indicated. Rationale: Medications that can affect the respiratory ventilation.

Strategies for Reading Critically

Critical Thinking is "the provision carefully and do not rush to whether we should accept, reject or suspend judgment on a claim, and the level of confidence with which we accept or reject it." of Critical Thinking by Moore and Parker.

Strategies for reading critically

Ask the following questions to yourself:
  1. What is the topic?
  2. What conclusions drawn by the author about the topic?
  3. What reasons expressed by the author who can be trusted? (Beware the objective reasons (eg pity, fear, abuse statistics, etc.) that can fool the reader.)
  4. Is the author using facts or opinions? (The fact can be proved. Opinions can not be proven and may not have a solid foundation.)
  5. Is the author using neutral words or emotional? (Readers critical look behind the words to see if obvious reasons.)

Characteristics of Critical Thinking
  1. Critical thinking is reasonable and rational.
  2. Critical thinking is reflective.
  3. Critical thinking inspires an attitude of inquiry.
  4. Critical thinking is autonomous thinking.
  5. Critical thinking includes creative thinking.
  6. Critical thinking is fair thinking.
  7. Critical thinking focuses on Deciding what to believe or do

The Meaning of Critical Thinking

Critical Thinking

The Meaning of Critical Thinking

Critical Thinking skills are essential skills for life, work, and function effectively in all aspects of life. Critical thinking has long been the ultimate goal in education since 1942. According Halpen (1996), critical thinking is empowering skills or cognitive strategies for goal setting. The process was passed after setting goals, consider, and refers directly to the target-is a form of thinking that needs to be developed in order to solve problems, formulate conclusions, collect various possibilities, and make a decision when to use all these skills effectively in the proper context and type. Critical thinking is also an activity-evaluate the conclusions that will be taken into account when determining the number of factors to support decision making. Critical thinking is also called directed thinking because thinking directly to the focus should be. The same opinion was expressed Anggelo (1995: 6), applying critical thinking is rational, high thinking activities, which include, activities analyze, synthesize, identify problems and solutions, summarize, and evaluate.

Emphasis on the process and stages of thought expressed also by Scriven, critical thinking is the intellectually active and full of skill in making sense or concept, applying, analyzing, making synthesis, and evaluation. All activities are based on observation, experience, reflection, reasoning, and communication, which will guide you in determining attitudes and actions (Walker, 2001: 1). The statement reiterated by Angelo (1995: 6), that critical thinking should meet the characteristics of the thinking include: analysis, synthesis, problem recognition and solving, conclusions, and judgment.

Matindas also revealed that many people are not so distinguish between critical thinking and logical thinking when there is a big difference between the two, namely that critical thinking was made to make a decision while thinking logically just needed to make a conclusion. Critical thinking involves logical thinking is also forwarded to the decision-making. From the opinions of the above can be said that the critical thinking that includes two major step which is doing the thinking process logic (reasoning) followed with decision making / problem solving (Deciding / problem solving). Thus it can also be interpreted that without adequate ability to think in terms of reasoning (deductive, inductive and reflective), one can not perform critical thinking processes correctly.

10 Factors Affecting the Quality and Quantity of Sleep

10 Factors Affecting the Quality and Quantity of Sleep

Many factors affect the quality or quantity of sleep, among which are diseases, environment, fatigue, lifestyle, emotional stress, stimulants and alcohol, diet, smoking, and motivation.

1. Disease.
The disease can lead to pain or physical distress that can cause sleep disorders. Individuals who are sick need more sleep than usual, in addition, sleep-wake cycles during illness may also experience interference.

2. Environment.
Environmental factors can help as well as hinder the process of sleep. The absence of a particular stimulus or the presence of foreign stimulus could undermine efforts to sleep. For example, the temperature is uncomfortable or poor ventilation can affect one's sleep. However, individuals can adapt over time and are no longer affected by the condition.

3. Fatigue.
Tired body condition can affect a person's sleep patterns. The more tired you are, the shorter REM sleep cycle in its path. After resting normally elongated REM cycle will return.

4. Lifestyle.
Individuals who frequently change working hours should regulate their activities in order to sleep at the right time.

5. Emotional stress.
Anxiety and depression often disturb one's sleep. conditions of anxiety can increase blood levels of norepinephrine by stimulating the nervous system simapatis.

6. Stimulants and alcohol.
Caffeine in some drinks can stimulate the central nervous system that can disrupt sleep patterns. While excessive alcohol consumption can disrupt the sleep cycle "REM". When the influence of alcohol has been lost, individuals often experience nightmares.

7. Diet.
Weight loss was associated with decreased sleep and frequent waking at night. In contrast, weight gain was associated with increased total sleep period and the least awake at night.

8. Smoking.
Nicotine contained in cigarettes has a stimulating effect on the body. As a result, smokers often difficult to sleep and wake up at night easy.

9. Medication.
Certain drugs can affect a person's quality of sleep. Hypnosis can interfere with stages III and IV sleep "NREM", metabloker can cause insomnia and nightmares, while the drug is known to suppress sleep "REM" and cause frequent waking at night.

10. Motivation.
The desire to stay awake sometimes can mask a person's feeling tired. conversely, feelings of boredom or lack of motivation to awake can often bring drowsiness.

Nursing Care in Children with Diarrhea and Typhoid

Nursing Care in Children with Disorders of the Digestive System Caused by Diarrhea and Typhoid

Theoretical Overview

Gastrointestinal tract plays a role in a series of processes: the process of food ingestion, digestion of food process, aided by the digestive fluid produced by the salivary glands, liver and pancreas. The results of digestion of nutrients will be absorbed into the body. This process takes place starting from the mouth to the rectum.

Disorders of the gastrointestinal tract in infants and children can be caused by congenital abnormalities. Disorders caused by abnormalities that can be caused by either trauma or infection of the gastrointestinal tract or the outside of the gastrointestinal tract. Congenital abnormalities can occur in the mouth, esophagus, pylorus, and duodenum in the passage disorder, rectal atresia, and imperforate anus, Hirschsprung disease, biliary obstruction, and omphalocele. While the disorder can be caused by an infection caused by a fungus "Candida albicans"; bacillus coli "Escherichia coli", viruses; germ: Salmonella, Shigella, Vibrio cholerae and parasites.

Various gastrointestinal disorders are common in children such as diarrhea and typhoid, the disease can affect gastrointestinal function and immune reaction that would lead to acute symptoms and complications that will stimulate the occurrence of changes in the digestive tract itself.

Diarrhea can be caused by various infections, in addition to other causes such as malabsorption. Diarrhea especially in infants need to get immediate action because it can lead to disaster if tackled late. Food and drinks were contaminated as stale food and toxic, is one of the factors causing diarrhea, so the disease is considered to be highly vulnerable to children going through a period of growth and development.

Nursing Care Plan for Diarrhea

Definition of Diarrhea

Diarrhea is a state frequency of bowel movements more than 4 times in infants and more than 3 times in children, with the consistency of watery, green can be, or can be mixed with mucus and blood or mucus alone.

Diarrhea is a symptom that occurs because of abnormalities involving the functions of digestion, absorption, and secretion. Diarrhea is caused by the transport of water and electrolytes in the gut abnormal. In the world there are approximately 500 million children suffering from diarrhea each year, and 20% of all deaths in developing countries living associated with diarrhea and dehydration. Diarrheal disorders can involve disorders of the stomach and intestines (gastroenteritis), small intestine (enteritis), colon, or the colon and intestines. Diarrhea is usually classified as acute and chronic diarrhea. (Dona L.Wong, 2008)

Clinical Manifestation

At first the patient whiny, insecure, body temperature usually increases, decreased appetite or no, then arise diarrhea. Liquid stool, possibly with mucus, or mucus and blood. The longer the stool color turns greenish because it is mixed with bile. Anus and surrounding area blisters arise due to frequent defecation and fecal increasingly acidic as a result of the more lactic acid derived from lactose that is not absorbed by the intestine during diarrhea. Symptoms of vomiting can occur before or after the diarrhea and stomach can be caused by inflammation or due to interference contribute acid-base and electrolyte balance. If the patient has a lot of fluid and electrolyte loss, dehydration symptoms begin to appear, ie weight loss, reduced turgor, eyes and large fontanel becomes concave (in infants, lips and mucous membranes of the mouth and the skin looks dry.

Nursing care Plan for Typhoid Fever

Definition of Typhoid

Typhoid fever is an acute infectious disease that usually affects the gastrointestinal tract with symptoms of fever more than a week, digestive disorders and disorders of consciousness. The cause of this disease is Salmonella typhi, gram-negative bacillus that moves with fur shakes, no spores.

Clinical Manifestation

Clinical Manifestation of typhoid fever in children are usually milder than in adults. Future shoots 10-20 days. The shortest 4 days if the infection occurs through food, whereas if through drink longest 30 days. During the incubation period may be found prodromal symptoms, ie feeling of malaise, lethargy, headache, dizziness not excited and lack of appetite.

Clinical features commonly found are:

1. Fever
In the typical case, the fever lasts 3 weeks, and remittances are febrile temperature is not very high. During the first week, the temperature gradually increased each day, usually down in the morning and rose again on the afternoon and evening. In the second week the patient continues to be in a state of fever, in the third week of temperatures going down and back to normal by the end of the third week.

2. Disorders of the gastrointestinal tract.
In the mouth there is a breath smells, lips dry and chapped. Tongue covered with dirty white membrane (coated tongue), red tip and edges, often accompanied by tremors. Abdominal bloating can be found condition (meteorismus). Enlarged liver and spleen accompanied by pain on palpation. Usually frequent constipation or diarrhea, but can also be normal.

3. Disorders of consciousness
Patient awareness generally decreased, although not in the apathetic until somnolence, rare sopor, coma or nervous (except severe illness and delayed treatment).Clinical Manifestation
Clinical Manifestation of typhoid fever in children are usually milder than in adults. Future shoots 10-20 days. The shortest 4 days if the infection occurs through food, whereas if through drink longest 30 days. During the incubation period may be found prodromal symptoms, ie feeling of malaise, lethargy, headache, dizziness not excited and lack of appetite.

Pain Assessment Method Based PQRST

Pain Assessment Method Based PQRST

Pain Assessment Method Based PQRST

P-Provocative, palliative factors
  • What might cause pain ...?
  • Is it because of an impact ..?
  • Due incision ..? etc..

  • How severe pain felt ..?.
  • How does it feel ..?.
  • How often happen ..?
  • Ex: As punctured, depressed / crushed by heavy objects, sliced ​​to pieces, etc..

  • Location where pain is felt / found ..?
  • Is also spread to other areas / areas spread ..?

  • The scale of gravity can be viewed using the GCS (Glasgow Coma Scale) for disorders of consciousness, pain scale / other size-related complaints.

  • When the pain started to find / feel ..?
  • How often does the pain feel / going on ...?
  • Are occurs suddenly or gradually ..?
  • Acut or chronic ..?

Nursing Care Plan for Hypertension in Pregnancy

Nursing Care Plan for Hypertension in Pregnancy
Hypertension in Pregnancy
Hypertension in pregnancy is a vascular disorder that occurs before pregnancy or arising in pregnancy or in the early postpartum. However, we discuss in this paper only which arise hypertension during pregnancy. Class of diseases characterized by high blood pressure and sometimes accompanied by proteinuria, edema, convulsi, coma, or other symptoms.

Clinical manifestations for mild hypertension in pregnancy include:
  • Diastolic blood pressure less than 100 mmhg.
  • Proteinuria fainter until --- +1
  • Minimal elevation of liver enzymes
Clinical manifestations to severe hypertension in pregnancy include:
  • Diastolic blood pressure of 110 mmHg or more
  • Persistent proteinuria + 2 or more
  • headache
  • Impaired vision
  • Upper abdominal pain
  • Oliguria
  • Convulsions
  • Creatinine increased
  • Thrombocytopenia
  • Increased liver enzymes
  • Stunted fetal growth
  • Pulmonary edema
Nursing Care Plan for Hypertension in Pregnancy

Nurses need a scientific method in the therapeutic process of the nursing process. The nursing process is used to assist nurses in nursing practice systematic in addressing the existing nursing.

Provision of nursing care is a therapeutic process that involves working relationship with the client, family or community to achieve optimal levels of health.

The Data Collection

The data were collected or studied include:

1. The identity of the patient

In pregnant women aged less than 25 years of incidence tripled. In pregnant women older than 35 years can occur latent hypertension.

Although the proportion of pregnancies with gestational hypertension in the United States in the past decade increased by almost a third. This increase was partly due to an increasing number of older mothers and multiple births. For example, in 1998 the birth rate among women aged 30-44 and the number of births to women age 45 and older are at the highest level in three decades, according to the National Center for Health Statistics. Furthermore, between 1980 and 1998, the rate of twin births increased by about 50 percent overall and 1,000 percent among women ages 45-49; levels of triplet and higher order multiple births jumped more than 400 percent overall and 1,000 percent in among women in their 40s.

2. The main complaint

Patients with hypertension in pregnancy is obtained in the form of complaints such as headaches, especially neck area can even dizzy eyes, eyes blurred, proteinuria (protein in the urine), sensitive to light, painful heartburn.

3. History of present illness

In patients with heart disease, hypertension in pregnancy, usually preceded by signs of easy fatigue, headache (not relieved by common analgesics), diplopia, upper abdominal pain (epigastric), oliguria (less than 400 ml per 24 hours) and nocturia and so on. It should also be asked if the client suffers from diabetes, kidney disease, rheumatoid arthritis, lupus or scleroderma, also need to be asked when the complaints began to appear. What action has been taken to reduce or eliminate these complaints.

4. History of the disease before
It should be asked whether the patient had been suffering from chronic diseases such as hypertension (high blood pressure before becoming pregnant), Obesity, anxiety, angina, dyspnea, orthopnea, hematuria, nocturia, and so on. Mother two times greater risk when pregnant couples who had previously been the father of the pregnancy disease. New couples return risk as primigravida mother. It is necessary to determine possible predisposing factors.

5. Family history of disease

It should be asked whether there are family members who suffer from diseases that are pointed out as the cause of cardiac hypertension in pregnancy. There is a genetic relationship has been investigated. Family history mother or sister increases the risk of four to eight times.

6. Psychosocial History

Includes patient feeling against the disease, how to cope and how the patient's behavior towards the action taken against him.

7. Maternal history

Multiple pregnancies have a greater risk than doubled.

Assessment of Body Systems

B1 (Breathing)

Respiratory include shortness of breath after activity, cough with or without sputum, smoking history, medication use a respirator, additional breath sounds, cyanosis.

B2 (Blood)

Impaired cardiovascular function is basically associated with increased cardiac afterload due to hypertension. In addition there is hemodynamic changes, changes in blood volume in the form of hemoconcentration. Impaired blood clotting time thrombin becomes elongated. The most typical is thrombocytopenia and clotting factor disorders, such as decreased levels of antithrombin III. Circulation includes a history of hypertension, heart disease, coroner, episodes of palpitations, increased blood pressure, tachycardia, sometimes S2 heart sounds heard at the base, S3 and S4, the increase in blood pressure, pulse throbbing clear from the carotid, jugular, radial, tachycardia, valvular stenosis murmur, jugular venous distention, pale skin, cyanosis, cold temperatures.

B3 (Brain)

These lesions are often due to rupture of cerebral blood vessels due to hypertension. Radiological abnormalities of the brain can be demonstrated by CT scan or MRI. The brain can suffer vasogenik edema and hypoperfusion. EEG examination also showed EEG abnormalities, especially after the seizure that can survive in the long seminggu.Integritas ego include anxiety, depression, euphoria, irritability, tense face muscles, nervous, respiratory heaved, increased speech patterns. Neuro-sensory complaints include headache, throbbing, sub-occipital headache, weakness on one side of the body, visual disturbances (diplopia, blurred vision), epistaxis, increased pressure on cerebral blood vessels.

B4 (Bladder)

History of kidney disease and diabetes mellitus, history of diuretic drugs also need to be studied. As in other glomerulopathy there is an increased permeability to most of the high molecular weight proteins. Most studies of kidney biopsy showed glomerular capillary endothelial swelling called endoteliosis glomerular capillary. Hemorrhagic necrosis of the liver lobules periporta peripheral section is most likely the cause of increased levels of liver enzymes in the serum.

B5 (Bowel)

Food / liquids include preferred food especially those containing high salt, protein, high fat, and cholesterol, nausea, vomiting, weight changes, edema.

B6 (Bone)

Pain / discomfort include intermittent pain in the limbs, sub-occipital headache severe, abdominal pain, chest pain, heartburn. Security include gait disturbance, paresthesias, postural hypotension.

Nursing Diagnosis and Interventions Risk for Injury - Seizures

Risk for Injury - Seizures

Nursing Care Plan for Epilepsy

Nursing Diagnosis : Risk for Injury

Risk for Injury related to uncontrolled seizure activity (balance disorder).

  • Clients can identify the precipitation of an attack and to minimize / avoid it, creating a state that is safe for the client, avoid any physical injury, avoid falling.

Expected outcomes:
  • no physical injury to the client, 
  • client is in a safe condition, 
  • no bruises, 
  • no fall.

Nursing Diagnosis and Interventions Risk for Injury - Seizures


1. Identification of environmental factors that allow the risk of injury.
The stuff around the patient may be harmful during the seizure.

2. Monitor neurological status every 8 hours
Identify deviations of development or expected results

Independent :

3. Keep objects that could cause injury to the patient during a seizure.
Reduce the occurrence of injury as a result of uncontrolled seizure activity.

4. Install the barrier the patient's bed.
Safeguards for security, to prevent injury or fall

5. Place the patient in a low and flat.
Areas of low and flat to prevent injury to the patient.

6. Together with the patient in some time after the seizure.
Providing safeguards for patient safety for the possibility of back spasms.

7. Prepare a soft cloth to prevent biting the tongue occurs during seizures.
Potentially bitten tongue during seizures because of sticking out.

8. Ask the patient if there are unusual feelings experienced just before a seizure.
To identify early manifestation before the occurrence of seizures in patients.


9. Provide anti-convulsive fit your doctor's advice.
Reduce prolonged seizure activity, which could reduce the supply of oxygen to the brain


10. Instruct patient to tell if there is something that does not feel comfortable, or experience something unusual for a start having seizures.
For information on the nurses to take immediate action before the seizures continued.

11. Provide information to the family about what to do during the patient's seizures.
Involving families to reduce the risk of injury.

Nursing Diagnosis for Epilepsy

Nursing Diagnosis for Epilepsy

Nursing Care Plan for Epilepsy

Epilepsy is a condition which affects the communication between the nerve cells of the nervous system when there is a sudden overactive electrical discharge in the brain. Epilepsy is a serious condition that affects millions of people across the globe.

There are many epilepsy symptoms to look out for. The largest one is the occurrence of epileptic seizures, which can come in a number of forms. Epileptic seizures can feel like a moment of confusion, a sudden blackout, a sudden change in smells or tastes, involuntary jerking of the legs and arms, and a long, blank staring spell. Epileptic seizures are essentially long moments of abnormal brain activity caused by electric signals that you generate in brain. This disease can usually be treated with the proper implementation and prescription of treatment drugs and possibly even surgery.

A seizure is a symptom of epilepsy, but not all seizures are caused by epilepsy.

A seizure not related to epilepsy can be caused by a reaction to:
  • A drug
  • A high fever
  • A severe head injury
  • Other disorders such diabetes, some heart conditions, and narcolepsy, among others.

Sometimes people have a single seizure for which no cause can ever be found.

Several conditions or behaviors mimic epilepsy but are not epilepsy.
  • Epilepsy is not a fainting disorder.
  • Epilepsy cannot be caused by holding the breath. Some children act out by holding their breath until they faint. This is not epilepsy.
  • Epilepsy is not momentary confusion, forgetfulness, or a lack of concentration.
  • Epilepsy is not catatonia, a specific type of schizophrenia characterized by stupor and bizarre movements.

Although epilepsy can start at any point during a person's life, most epilepsy is diagnosed in childhood, and most of all in the first year of life - around 140 out of every 100,000 babies under the age of one are diagnosed with epilepsy per year. This drops to 40 adults per 100,000. However, recent reports have shown that epilepsy is increasing in older people, who account for a quarter of all new diagnoses, according to a survey by the National Society for Epilepsy. The condition is twice as common in older people as it is in the population as a whole.

8 Nursing Diagnosis for Epilepsy

1. Risk for Injury
related to:
uncontrolled seizure activity (balance disorder).

2. Ineffective airway clearance
related to:
blockage of the tongue, endotracheal,
increased secretion of saliva

3. Social isolation
related to:
low-self against the disease state, and the bad stigma against epilepsy in the community.

4. Ineffective breathing pattern
related to:
dyspnoea and apneu

5. Activity intolerance
related to:
decreased cardiac output, tachycardia

6. Impaired sensory perception
related to:
disturbances in nerve sensory organs of perception

7. Anxiety
related to:
lack of knowledge about the disease

8. Risk for Ineffective cerebral Tissue Perfusion
related to:
decreased oxygen supply to the brain.

Skin and Wound Care Video

Fundamental of Nursing, Skin and Wound Care

Fundamental of Nursing

Skin and Wound Care Video

Skin and Wound Care series emphasize on the role of the nurse to describe factors affecting skin integrity and identifying clients at risk for pressure ulcers. The series describe the four stages of pressure ulcer development and differentiate primary and secondary wound healing and describes the three phases of wound healing. Part of the roles of the nurse include identifying assessment data pertinent to skin integrity, pressure sites, and wounds and identifying nursing diagnoses associated with impaired skin integrity.

Role of Nurses as Implementers, Educators, Managers and Researchers

The role of the nurse is a way to express the activities of nurses in practice, which has completed a formal education that is recognized and authorized by the government to carry out the task.

While the role of nurses include: providers of nursing care, nursing practice or practitioner, client education, management and research activities in the field of nursing.

1. Role of Nurses as Implementers

Nurses as Implementers

This role is known by the Care Giver, the role of nurses in providing nursing care, directly or indirectly, to the client as an individual, family and community, with a problem-solving approach called the nursing process. In performing this role the nurse acts as a comforter, protector, advocate, communicator and rehabilitator.

2. Role of Nurses as Educators

Nurses as Educators

As educators, nurses play a role in educating individuals, families, groups and communities and health workers who are under their responsibility. This role is in the form of counseling to clients, as well as the form of dissimilation knowledge to nursing students.

3. Role of Nurses as Managers

Nurses as Managers

In this case the nurse has a role and responsibility in managing the nursing care and education in accordance with the nursing management, within the framework of the nursing paradigm. As a nurse manager in monitoring and ensuring the quality of care or nursing services as well as organizing and controlling system of nursing care, as knowledge / understanding nurses less, so the nurse executive manager is not maximized, the majority position, scope of authority and responsibilities of nurses has almost no effect in the planning and decision-making.

4. Role of Nurses as Researchers

Nurses as Researchers

As a researcher in the field of Nursing, Nurse is expected to identify a research problem, apply the principles and methods of research and make use of research to improve the quality of care or service and nursing education. Research in the field of Nursing role in reducing inequalities in health technology mastery, as the findings of the study further enable the transformation of science and Technology, but it is important to strengthen efforts to establish and advance the profession of nursing. (Asdi, 2008)

Nanda Nursing Diagnosis for Atelectasis

Nursing Care Plan for Atelectasis

Nanda Nursing Diagnosis for Atelectasis

Atelectasis is defined as the collapse or closure of the lung resulting in reduced or absent gas exchange. It may affect part or all of one lung. It is a condition where the alveoli are deflated, as distinct from pulmonary consolidation.

Atelectasis may be an acute or chronic condition. In acute atelectasis, the lung has recently collapsed and is primarily notable only for airlessness. In chronic atelectasis, the affected area is often characterized by a complex mixture of airlessness, infection, widening of the bronchi (bronchiectasis), destruction, and scarring (fibrosis).

Atelectasis is a very common finding in chest x-rays and other radiological studies. It may be caused by normal exhalation or by several medical conditions. Although frequently described as a collapse of lung tissue, atelectasis is not synonymous with a pneumothorax, which is a more specific condition that features atelectasis. Acute atelectasis may occur as a post-operative complication or as a result of surfactant deficiency. In premature neonates, this leads to infant respiratory distress syndrome.

Signs and symptoms of Atelectasis
  • cough, but not prominent
  • chest pain
  • breathing difficulty
  • low oxygen saturation
  • pleural effusion (transudate type)
  • cyanosis (late sign)
  • increased heart rate
  • low-grade fever

Treatment of Atelectasis

The goal of treatment is to re-expand the collapsed lung tissue. If fluid is putting pressure on the lung, removing the fluid may allow the lung to expand.

The following are treatments for atelectasis:
  • Clap (percussion) on the chest to loosen mucus plugs in the airway
  • Perform deep breathing exercises (with the help of incentive spirometry devices)
  • Remove or relieve any blockage by bronchoscopy or another procedure.
  • Tilt the person so the head is lower than the chest (called postural drainage). This allows mucus to drain more easily.
  • Treat a tumor or other condition, if there is one
  • Turn the person to lie on the healthy side, allowing the collapsed area of lung to re-expand
  • Use aerosolized respiratory treatments (inhaled medications) to open the airway
  • Use other devices that help increase positive pressure in the airways and clear fluids (positive and expiratory pressure [PEP] devices)

7 Nanda Nursing Diagnosis for Atelectasis

1. Ineffective breathing pattern
related to:
Excessive mucus production and thick,
ineffective cough.

2. Impaired gas exchange
related to:
Lung volume reduction

3. Activity Intolerance
related to:
weak body condition (fatigue) secondary to increased respiratory effort.

4. Risk for fluid volume deficits
related to:
fever fluid loss,
fluid intake is less because of dyspnoea.

5. Acute Pain
related to:
lung inflammation

6. Anxiety
related to:
hospitalization (ICU)

7. Knowledge Deficit
related to:
lack of information about the disease process, treatment procedures at the hospital.

The Basic Concept of Nursing Models and Nursing Process by Sister Callista Roy

Sister Calista Roy Adaptation Model
Sister Callista Roy (born October 14, 1939) is an American nursing theorist, professor and author. She is known for creating the adaptation model of nursing. Roy was designated as a 2007 Living Legend by the American Academy of Nursing.

At age 14 she began working at a large general hospital, first as a pantry girl, then as a maid, and finally as a nurse's aid. After a soul-searching process of discernment, she decided to enter the Sisters of Saint Joseph of Carondelet, of which she has been a member for more than 40 years. Her college education began in a liberal arts program, where she earned a Bachelor of Arts with a major in nursing at Mount St. Mary's College, in Los Angeles.

During her graduate studies, Roy was compelled by instructor Dorothy Johnson to write a conceptual model of nursing. The Roy Adaptation Model was first published in Nursing Outlook in 1970. In this model, humans (as individuals or in groups) are holistic, adaptive systems. The environment consists of internal and external stimuli that surround an individual or group. Health is seen as a sound, unimpaired condition leading to wholeness. Nursing's goal is to promote modes of adaptation that support overall health.

Four modes of adaptation support integrity: physiologic-physical, self-concept group identity, role function and interdependence. In applying Roy's model, the following steps may help to integrate it with the traditional nursing process: assessment of client behavior; assessment of stimuli; nursing diagnosis; goal setting; interventions; and evaluation.

In 1976, Sister Callista Roy developed the Adaptation Model of Nursing, a prominent nursing theory. Nursing theories frame, explain or define the provision of nursing care. Roy's model sees the an individual as a set of interrelated systems (biological, psychological and social). The individual strives to maintain a balance between these systems and the outside world, but there is no absolute level of balance. Individuals strive to live within a unique band in which he or she can cope adequately.

Major Assumptions, Concepts and Relationships Assumptions

In the Adaptation Model, assumptions are specified as scientific assumptions or philosophical assumptions.

Scientific Assumptions

    Systems of matter and energy progress to higher levels of complex self- organization.
    Consciousness and meaning are constitutive of person and environment integration
    Awareness of self and environment is rooted in thinking and feeling
    Humans by their decisions are accountable for the integration of creative processes.
    Thinking and feeling mediate human action
    System relationships include acceptance, protection, and fostering of interdependence
    Persons and the earth have common patterns and integral relationships
    Persons and environment transformations are created in human consciousness
    Integration of human and environment meanings results in adaptation (Roy&Andrew, 1999, p.35).

Philosophical Assumptions

    Persons have mutual relationships with the world and God
    Human meaning is rooted in the omega point convergence of the universe.
    God is intimately revealed in the diversity of creation and is the common destiny of creation.
    Persons use human creative abilities of awareness, enlightenment, and faith.
    Persons are accountable for the processes of deriving, sustaining and transforming the universe (Roy & Andrew, 1999, p. 35).


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Children's Information
We believe it is important to provide added protection for children online. We encourage parents and guardians to spend time online with their children to observe, participate in and/or monitor and guide their online activity.
http://nanda-nurse-diary.blogspot.com/ does not knowingly collect any personally identifiable information from children under the age of 13. If a parent or guardian believes that http://nanda-nurse-diary.blogspot.com/ has in its database the personally-identifiable information of a child under the age of 13, please contact us immediately (using the contact in the first paragraph) and we will use our best efforts to promptly remove such information from our records.

Online Privacy Policy Only

This privacy policy applies only to our online activities and is valid for visitors to our website and regarding information shared and/or collected there.
This policy does not apply to any information collected offline or via channels other than this website.

By using our website, you hereby consent to our privacy policy and agree to its terms.

This Privacy Policy was last updated on: Sunday, November 18th, 2012.
Privacy Policy Online Approved Site
Should we update, amend or make any changes to our privacy policy, those changes will be posted here.