Acute Pain and Activity Intolerance - NCP Angina Pectoris

Acute Pain and Activity Intolerance - NCP Angina Pectoris

Nursing Diagnosis Care Plan Angina Pectoris

Angina pectoris is the result of myocardial ischemia caused by an imbalance between myocardial blood supply and oxygen demand.

Angina, or angina pectoris, is the medical term used to describe the temporary chest discomfort that occurs when the heart is not getting enough blood.

Not all chest pain is angina. Pain in the chest can come from a number of causes, which range from not serious to very serious.

For example, chest pain can be caused by:

• acid reflux (gastroesophageal reflux disease, GERD),
• upper respiratory infection,
• asthma, or
• sore muscles and ligaments in the chest (chest wall pain)

Go to a hospital emergency department if the patient has any of the following with chest pain:

• Other symptoms such as: sweating, weakness, faintness, numbness or tingling, or nausea
• Pain that does not go away after a few minutes
• Pain that is of concern in any way

Acute Pain Nanda Definition : 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

Activity Intolerance Nanda Definition : Insufficient physiological or psychological energy to endure or complete required or desired daily activities.

Nursing Diagnosis and Interventions for Angina Pectoris

1. Acute Pain related to myocardial ischemic


Intervention :

• Assess the factors that aggravate the pain.
• Create a calm environment, limit the visitor when necessary.
• Give soft foods and let the client rest 1 hour after meals.
• Stay with clients who are experiencing pain or anxious.
• Put the client on bed rest during episodes of angina (the first 24-30 hours) with a semi-Fowler position.
• Observation of vital signs every 5 minutes every attack of angina.
• Teach distraction and relaxation techniques.
• Collaboration treatment.

2. Activity intolerance related to decreased cardiac output

Intervention :

• Increase client activity on a regular basis.
• ECG Monitor with frequently.
• Maintain bed rest in a comfortable position.
• Provide adequate rest periods, aids in the fulfillment of self-care activities as indicated.
• Note skin color and pulse quality.

NCP - Nursing Diagnosis for Depression with Interventions

NCP - Nursing Diagnosis for Depression with Interventions

Nanda Nursing Care Plan for Depression

Depression is a natural kind of feeling or emotion that accompanied psychological component: think hard, gloomy, sad, hopeless and unhappy, and somatic components: anorexia, constipation, skin moist (cold), blood pressure and pulse rate decreased slightly.

Depression is caused by many factors including: heriditer factors and genetic, constitutional factors, premorbid personality factors, physical factors, psychobiology factors , neurologic factors, biochemical factors in the body, factors electrolyte balance and so on.

Depression is usually triggered by physical trauma such as infectious disease, surgery, accidents, labor and so on, as well as psychic factors such as loss of love or self-esteem and the effect of hard work.

Depression is a normal reaction when it takes place in a short time, with a clear trigger, long and deep depression that factor originators. Psychotic depression is when a complaint is concerned no longer compatible with reality, not to judge reality and can not be understood by others.

The data needs to be assessed in patients with Depression

1. Depression

a. Subjective data:
Not being able to express their opinions and lazy talk. Often argued somatic complaints. Feeling themselves are not useful anymore, no meaning, no purpose in life, feeling hopeless and suicidal.

b. Objective data:
Body movements were blocked, curved body and when sitting with slumped attitude, facial expressions moody, slow gait dragged by step. It can sometimes happen stupor. Patients seem lazy, tired, no appetite, difficulty sleeping and crying.
The thinking process too late, as if his mind blank, impaired concentration, had no interest in, can not think, do not have any imagination. In patients with depressive psychosis there is a deep sense of guilt, unreasonable (irrational), Objective Data delusions, depersonalization, and hallucinations.
Sometimes patients prefer hostile, irritable and do not like to be disturbed.

2. Maladaptive coping

a. Subjective Data: declare hopeless and helpless, unhappy.
b. Objective Data: look sad, irritable, agitated, unable to control impulses.


Nursing Diagnosis for Depression

1. Risk for Self Harm related to depression
2. Depression related to maladaptive coping.


Nursing Interventions for Depression

General Purpose: Clients do not self-injure.

Specific Purpose:

1. Clients can build a trusting relationship

Action:

• Introduce yourself to the client
• Interact with the patient as much as possible with the four attitudes.
• Listen to patient statements, patient manner, empathy and use more non-verbal language. For example: a touch, a nod of the head.
• Note the patient talks and give responses according to her wishes.
• Speak with a low tone of voice, clear, concise, simple and easy to understand.
• Accept the patient is without comparing with others.

2. Clients can use adaptive coping

Action:

• Give encouragement to express his feelings and said that nurses understand what the patient feels.
• Ask the patient the usual way to overcome feeling sad / painful.
• Discuss with patients the benefits of coping used.
• With patients looking for alternatives coping.
• Encourage the patient to choose the most appropriate coping and acceptable.
• Encourage the patient to try to coping have been.
• Instruct the patient to try other alternatives in solving the problem.

3. Clients are protected from self injuring behavior

Action:

• Monitor carefully the risk of suicide / self-mutilation.
• Keep and store the tools that can be used by patients to injure himself / others, in a safe and locked.
• Keep the tool material harm to the patient.
• Supervise and place the patient in a room that is easily monitored by nurses.

4. Clients can increase self-esteem

Action:

• Help to understand that the client can overcome despair.
• Assess and internal sources mobilized individuals.
• Help to identify the sources of expectations (eg, interpersonal relationships, beliefs, things to be resolved).

5. Clients can use social support

Action:

• Assess and use individual external sources (those closest to the team of health care, support groups, religious affiliation).
• Assess support systems beliefs (values, past experiences, religious activities, religious beliefs).
• Make referrals as indicated (eg, counseling, religious leaders).

6. Clients can use the medication correctly and appropriately

Action:

• Discuss medications (name, frequency, effects and side effects of medication).
• Help for using drugs; really patient, medication, method, period.
• Encourage talking about the effects and side effects are felt.
• Give positive reinforcement when using the drug properly.

Knowledge Deficit related to Dysmenorrhea

Knowledge Deficit related to Dysmenorrhea

Nursing Diagnosis Knowledge Deficit- NCP Dysmenorrhea

Dysmenorrhea is the occurrance of painful cramps during menstruation.
Dysmenorrhea is called "primary" when there is no specific abnormality, and "secondary" when the pain is caused by an underlying gynecological problem. It is believed that primary dysmenorrhea occurs when hormone-like substances called "prostaglandins" produced by uterine tissue trigger strong muscle contractions in the uterus during menstruation.

Knowledge deficit is a lack of cognitive information or psychomotor skills required for health recovery, maintenance, or health promotion. Teaching may take place in a hospital, ambulatory care, or home setting. The learner may be the patient, a family member, a significant other, or a caregiver unrelated to the patient. Learning may involve any of the three domains: cognitive domain (intellectual activities, problem-solving, and others), affective domain (feelings, attitudes, beliefs), and psychomotor domain (physical skills or procedures).

Nursing Diagnosis : Knowledge Deficit related to lack of information

Goal : Patients know, understand, and comply with the therapeutic program

Expected outcomes: The patient understand the illness and what it affects.

Interventions and Rational :

1. Help patients understand the purpose of short-term and long-term.
Rational: Preparing the patient to treat the condition and improve the quality of life.

2. Teach patients about the disease and its treatment.
Rational: to teach the patient about his condition is one of the most important aspects of treatment.

3. Provide emotional support.
Rationale: Allows clients to be positive.

4. Involve the people closest to the teaching program, provide instructional materials / written instructions.
Rationale: Helps to increase knowledge and provide additional resources for home care reference.

Risk for Infection - NCP Anemia

Risk for Infection - NCP Anemia

Nursing Diagnosis for Anemia

Risk for infection related to secondary immune inadequate (eg, hemoglobin decreased, suppression / decrease the inflammatory response).

Goal:

Identify the behavior to prevent / reduce the risk of infection.

1. Do a good hand washing by caregivers and patients.
2. Maintain strict aseptic technique on the procedure / treatment of wounds.
3. Increase your fluid intake is adequate.
4. Monitor temperature, note the presence of chills and tachycardia with or without fever.
5. Collaboration: give antiseptic topical, systemic antibiotics.

Rational:
1. Prevent cross-contamination.
2. Reduce the risk of bacterial infection.
3. Assist in breathing secret dilution to facilitate spending and prevent static body fluids.
4. The process of inflammation / infection require evaluation / treatment.
5. Perhaps the prophylactic use to reduce colonization or for the treatment of local infections.

Activity Intolerance related to Pain of Dysmenorrhea

Activity Intolerance related to Pain of Dysmenorrhea

Nursing Care Plan for Dysmenorrhea : Nursing Diagnosis Activity Intolerance related to Pain

Dysmenorrhea is a gynecological medical condition of pain during menstruation that interferes with daily activities, as defined by ACOG and others.

There are two types of dysmenorrhea: "primary" and "secondary".

Primary dysmenorrhea is common menstrual cramps that are recurrent and are not due to other diseases. Cramps usually begin one to two years after a woman starts getting her period. Pain usually begins 1 or 2 days before or when menstrual bleeding starts and is felt in the lower abdomen, back, or thighs and can range from mild to severe. Pain can typically last 12 to 72 hours and can be accompanied by nausea, vomiting, fatigue, and even diarrhea. Common menstrual cramps usually become less painful as a woman ages and may stop entirely if the woman has a baby.

Secondary dysmenorrhea is pain that is caused by a disorder in the woman's reproductive organs, such as endometriosis, adenomyosis, uterine fibroids, or infection. Pain from secondary dysmenorrhea usually begins earlier in the menstrual cycle and lasts longer than common menstrual cramps. The pain is not typically accompanied by nausea, vomiting, fatigue, or diarrhea.

The main symptom of dysmenorrhea is pain concentrated in the lower abdomen, in the umbilical region or the suprapubic region of the abdomen. It is also commonly felt in the right or left abdomen. It may radiate to the thighs and lower back.

Symptoms often co-occurring with menstrual pain include nausea and vomiting, diarrhea or constipation, headache, dizziness, disorientation, hypersensitivity to sound, light, smell and touch, fainting, and fatigue. Symptoms of dysmenorrhea often begin immediately following ovulation and can last until the end of menstruation. This is because dysmenorrhea is often associated with changes in hormonal levels in the body that occur with ovulation. The use of certain types of birth control pills can prevent the symptoms of dysmenorrhea, because the birth control pills stop ovulation from occurring.

Nursing Care Plan for Dysmenorrhea 

Nursing Diagnosis Activity Intolerance related to Pain

Goal :

Showed improved activity tolerance

Expected outcomes: the patient can perform activities

Nursing Interventions :

1.Avoid frequent intervention is not important which can make tired, give adequate rest.
Rational : Adequate rest can reduce stress and increase comfort.

2. Provide adequate rest and sleep 8-10 hours each night.
Rational : Adequate rest and sleep enough to reduce fatigue and increase resistance to infection.

3. Provide adequate rest and sleep 8-10 hours each night.
Rational : Adequate rest and sleep enough to reduce fatigue and increase resistance to infection.

4. Observations over the level of pain, and motor response, 30 minutes after drug administration to assess the analgesic effectiveness. And every 1-2 hours after the maintenance action for 1-2 days.
Rational : The assessment will provide optimal nursing objective data to prevent possible complications and appropriate interventions.

5 Nursing Diagnosis for Acne Vulgaris

5 Nursing Diagnosis for Acne Vulgaris

Nursing Care Plan for Acne Vulgaris

Acne vulgaris (cystic acne or simply acne) is a common human skin disease, characterized by areas of skin with seborrhea (scaly red skin), comedones (blackheads and whiteheads), papules (pinheads), pustules (pimples), nodules (large papules) and possibly scarring.

Acne occurs most commonly during adolescence, and often continues into adulthood. In adolescence, acne is usually caused by an increase in testosterone, which accrues during puberty, regardless of sex. For most people, acne diminishes over time and tends to disappear — or at the very least decreases — by age 25. There is, however, no way to predict how long it will take to disappear entirely, and some individuals will carry this condition well into their thirties, forties, and beyond.

Common causes of Acne Vulgaris

• Increased androgen production
• Overactivity/hyperresponsiveness of sebaceous glands in response to androgens
• Colonization of Propionibacterium acnes, which metabolizes sebum to free fatty acid, leading to inflammatory lesions.

5 Nursing Diagnosis for Acne Vulgaris

1. Body image disturbance related to inflammatory lesions of acne.

2. Anxiety related to acne lesions.

3. Impaired skin integrity characterized by erythematous papules, pustules, and cysts inflammatory.

4. Risk for infection related to a bacterial skin infection.

5. Knowledge deficit related to acne triggers and treatments.

Nanda Herpes Simplex - Nursing Diagnosis

Nanda Herpes Simplex - Nursing Diagnosis

Nursing Diagnosis for Herpes Simplex

Herpes simplex is a viral disease from the herpesviridae family caused by both Herpes simplex virus type 1 (HSV-1) and type 2 (HSV-2). Genital herpes affects the genitals, buttocks or anal area. Genital herpes is a sexually transmitted disease (STD). It affects the genitals, buttocks or anal area. Other herpes infections can affect the eyes, skin, or other parts of the body. The virus can be dangerous in newborn babies or in people with weak immune systems.

Genital herpes, known simply as herpes, is the second most common form of herpes. Other disorders such as herpetic whitlow, herpes gladiatorum, ocular herpes, cerebral herpes infection encephalitis, Mollaret's meningitis, neonatal herpes, and possibly Bell's palsy are all caused by herpes simplex viruses.

HSV infection causes several distinct medical disorders. Common infection of the skin or mucosa may affect the face and mouth (orofacial herpes), genitalia (genital herpes), or hands (herpetic whitlow). More serious disorders occur when the virus infects and damages the eye (herpes keratitis), or invades the central nervous system, damaging the brain (herpes encephalitis). Patients with immature or suppressed immune systems, such as newborns, transplant recipients, or AIDS patients are prone to severe complications from HSV infections. HSV infection has also been associated with cognitive deficits of bipolar disorder, and Alzheimer's disease, although this is often dependent on the genetics of the infected person.

In all cases HSV is never removed from the body by the immune system. Following a primary infection, the virus enters the nerves at the site of primary infection, migrates to the cell body of the neuron, and becomes latent in the ganglion. As a result of primary infection, the body produces antibodies to the particular type of HSV involved, preventing a subsequent infection of that type at a different site. In HSV-1 infected individuals, seroconversion after an oral infection will prevent additional HSV-1 infections such as whitlow, genital herpes, and herpes of the eye. Prior HSV-1 seroconversion seems to reduce the symptoms of a later HSV-2 infection, although HSV-2 can still be contracted.

Many people infected with HSV-2 display no physical symptoms—individuals with no symptoms are described as asymptomatic or as having subclinical herpes.

Nanda Herpes Simplex - Nursing Diagnosis

1. Impaired skin integrity related to skin inflammation, crusting, vesicles.

2. Hyperthermia related to increased hypothalamic set point.

3. Acute Pain related to infection in pain neurons, the ganglia.

4. Fatigue related to reduction of energy sources.

5. Risk for Imbalanced Nutrition, Less Than Body Requirements related to appetite down.