Nursing Care Plan - Risk for Violent Behavior

Nursing Care Plan - Risk for Violent Behavior

Violence can be defined as the use of physical force with the intent to injure another person or destroy property, while aggression is generally defined as angry or violent feelings or behavior. A person who is aggressive does not necessarily act out with violence.

Risk for Violent Behavior

General goals :
The client can control violent behavior

Specific goals :

1. The client can build a trusting relationship

Expected outcomes:
The client shows signs of believing in the nurse:
Bright face, smiling.
Want to get acquainted.
No eye contact.
Willing to share feelings.

Nursing Inerventions :
Develop a relationship of trust with:
Greet each interaction.
Introduce the names, nicknames nurses and nurses interact purposes.
Ask and call the name of the client's favorite.
Show empathy, honesty and keeping promises whenever interacting.
Ask the client's feelings and problems faced by the client.
Create a clear interaction contract.
Listen attentively to client's expression of feelings.

2. The client can identify the causes of violent behavior accomplishments
Expected outcomes:
The client tells the causes of violent behavior is doing; tells cause annoyance / upset either of themselves or their environment

Nursing Intervetions :
Help clients express feelings of anger:
Motivation client to tell the cause of resentment or annoyance
Listen without interrupting or give an assessment of each client's expression of feelings

3. The client can identify signs of violent behavior
Expected outcomes:
The client tells the signs of violent behavior occurs when:
Physical signs: red eyes, hands clenched, tense expression, and others.
Signs of emotional: feelings of anger, resentment, spoke harshly.
Social sign: hostile experienced during a violent behavior.

Nursing Interventions :
Help the client revealed signs of violent behavior that happened:
Motivation of the client communicating the physical condition (physical signs) when the violent behavior happened
Motivation of the client to share his emotional condition (signs of emotional) during a violent behavior
Motivation of the client to tell the condition of relationship with others (social signals) during a violent behavior

4. The client can identify the type of violent behavior has ever done
Expected outcomes:
The client explained:
The types of anger expression that had been done
Felt when violence

Nursing Interventions :
Discuss with the client violent behavior is usually done:
Motivation of the client to tell the kinds of violence that had been done.
Motivation of the client communicating the client's feelings after the incident of violence occurred
Discuss whether the acts of violence that can overcome the problems experienced.

5. The client can be identified as a result of violent behavior
Expected outcomes:
The client explained that due to the violence that is done
Self: wounds, shunned friends, etc.
Another person / family: wound, irritability, fear, etc.
Environment: goods or broken objects, etc.
The effectiveness of the methods used in solving problems

Nursing Interventions :
Discuss with the client due to the negative (losses) on how that is done:
Self
Others / family
Environment

6. The client can identify constructive ways of expressing anger
Expected outcomes:
Explaining healthy ways of expressing angry

Nursing Interventions :
Discuss with the client:
Does the client want to learn a new way of expressing anger that healthy
Explain the various alternative options to express angry besides the known violent behavior by the client.
Explain healthy ways to express angry:
Ø physical way: a deep breath, hit a pillow or mattress, sports.
Ø Verbal: revealed that he was upset to others.
Ø Social: assertiveness training with others.
Ø Spiritual: prayer, meditation, etc according their religious beliefs

7. The client can demonstrate how to control violent behavior
Expected outcomes:
The client demonstrates how to control violent behavior:
Physical: take a deep breath, hit the pillow / mattress
Verbal: express the feeling irritated / annoyed at others without hurting
Spiritual: prayer, meditation accordance religion

Nursing Interventions :
Discuss ways that may be selected and encourage clients choose the possible ways to express anger.
Train showcase selected clients: demonstrate how to implement the chosen method, explain the benefits of this way, encourage clients imitating the demonstration that has been done, give reinforcement to the client, correct way is still not perfect.
Encourage clients to use tools already trained when angry / annoyed

8. The client has a family support to control violent behavior
Expected outcomes:
Explain how to care for a client with violent behavior
Expressed pleasure in caring for the client

Nursing Interventions :
Discuss the importance of the role of the family as a supporter of the client to address violent behavior.
Discuss potential families to help the client resolve violent behavior
Explain the meaning, causes, consequences and how to care for the clients of violent behavior that can be carried out by the family.
Demonstrate how to care for the clients (to handle violent behavior)
Give the family the opportunity to demonstrate again.
Give praise to the family after the demonstration

9. The client uses the appropriate therapy program that has been set
Expected outcomes:
The client explained:
Benefits of taking medication
Losses do not take medication
Medicine name
The shape and color of drugs
The dose given
time usage
How to use
Effects felt

Nursing Interventions:
Explain the benefits of using the medication regularly and damages if the client does not use medication
Explain to the client: the type (name, color and form of the drug), the dose is right for the client, time of use, how to use, the effect will be felt by the client.
Advise the client: Ask for and use of medication on time, Report to the nurse / physician if the client is experiencing unusual effects, Give praise to discipline the client using the drug, Ask the family feeling after trying ways trained.

Ineffective Individual Coping related to Bulimia Nervosa

Ineffective Individual Coping related to Bulimia Nervosa

Nursing Care Plan for Bulimia Nervosa

Bulimia nervosa is a disorder in eating habits. Eating disorders are a psychiatric syndrome that is characterized by eating patterns associated with aberrant psychological characteristics associated with eating, body shape and weight. eating disorders occur due to several reasons in eating behavior, such as consumption of less healthy foods or eating too much.

Bulimia nervosa is a feast of food, followed by washing stomach or vomiting. Eating disorders usually occur together with other diseases such as depression, being part of a violent, and anxiety disorders. In this case, people who suffer from eating disorders can experience physical health complications further, including the problem of the working conditions of liver and kidney failure, which can lead to death. Many people with bulimia have a normal weight and seem to be no significant problems in life. Their regular people who look healthy, successful in his field, and tend ferfeksionis. However, behind it, have low self-esteem and often depressed.


Nursing Diagnosis : Ineffective individual coping

Goal: ineffectiveness of individual coping can be met.

Expected outcomes:

• Identify methods that are not associated with less food in the face of stress or crisis.
• Expressed feelings of guilt, anxiety, anger, or excessive need for control.
• Shows a more satisfying interpersonal relationships.
• Revealed more realistic body image.
• Addressing an alternative method of dealing with stress or crisis.
• Revealed an increase in self-esteem and confidence.

Interventions :

• Assess client's eating habits.
• Encourage clients to eat with other clients or their families, if tolerated.
• Encourage clients to express their feelings (anxiety and guilt about eating).
• Encourage clients to keep a diary to write down the type and amount of food eaten, identify feelings experienced before and after eating, especially about excessive eating behavior and depletion.
• Discuss the client's preferred food and reduce anxiety.
• Help clients explore ways to overcome the emotions (anger, anxiety, and frustration).
• Give positive feedback to the client.
• Teach client about the use of problem-solving process.
• Exploration with the client about personal power.
• Discuss with the client about the idea of receiving underweight "ideal".
• Encourage clients to express their feelings, about the family members and those closest, role and relationship with them.

Rationale :

• Preventing overeating behavior that includes eating secretly and swallow food, helps clients quickly and return to normal diet (three times daily).
• Prevent secrecy about eating, though at first anxiety, the client may be too high to join the meal together.
• Helps reduce feelings verbally can reduce anxiety and reducing the depletion of food behaviors.
• Helping clients examine food intake and feelings they experienced.
• Helping clients looking at using food to cope with feelings or make it comfortable.
• Helping clients to separate emotional issues of food and eating behavior.
• Increase efforts to clients in the face of anxiety, anger, and other emotions honestly and openly.
• Helps clients improve self-esteem and confidence of clients.
• Helping clients find strength.
• Change the client's perception of ideal body weight may be unrealistic and unhealthy.
• Helping clients identify, accept, and cope with their feelings in a proper way.

Nursing Care Plan for Kawasaki Disease

Nursing Care Plan for Kawasaki Disease

Kawasaki disease (mucocutaneous lymph node syndrome) is a form of vasculitis identified by an acute febrile illness with multiple systems affected. Kawasaki fever is a fever in children is associated with vasculitis especially coronary blood vessels and other systemic complaints.

Kawasaki disease, also known as Kawasaki syndrome, lymph node syndrome, and mucocutaneous lymph node syndrome.

Kawasaki disease was described by and named after Japanese pediatrician Tomisaku Kawasaki in 1967. It is also called mucocutaneous lymph node syndrome or Kawasaki syndrome.

Kawasaki disease is largely seen in children under five years of age. Kawasaki disease affects many organ systems, mainly those including the blood vessels, skin, mucous membranes, and lymph nodes. Its rarest but most serious effect is on the heart, where it can cause fatal coronary artery aneurysms in untreated children.

The exact cause of Kawasaki disease is still unknown. Some studies suggest that it may be caused by the immune system’s reaction to an infectious agent, such as a virus. The condition itself is not contagious.

Early symptoms may include:

• High fever
• Bloodshot eyes (also known as “conjunctivitis without discharge”)
• Rash
• Swollen lymph nodes
• Swollen, bright red tongue
• Swollen hands and feet
• Red palms and soles of the feet

Later symptoms may include:

• Diarrhea
• Peeling skin on the hands and feet
• Vomiting
• Pain in the joints

Nursing Diagnosis for Kawasaki Disease :

1. Chronic pain related to inflammation of the myocardium or pericardium.
2. Risk for decreased cardiac output related to accumulation of fluid in the pericardial sac.
3. Activity intolerance related to inflammation and degeneration of myocardial muscle cells.

Hyperthermia related to Urinary Tract Infections

Hyperthermia related to Urinary Tract Infections

Nursing Care Plan for Urinary Tract Infections

A urinary tract infection (UTI) is an infection that affects part of the urinary tract. A urinary tract infection (UTI) (also known as acute cystitis or bladder infection). Urinary tract infections (UTIs) are very common – particularly in women, babies and the elderly. Around one in two women and one in 20 men will get a UTI in their lifetime.

The infection can occur at different points in the urinary tract, including:

• Urethra. An infection of the tube that empties urine from the bladder to the outside is called urethritis.
• Kidneys. An infection of one or both kidneys is called pyelonephritis or a kidney infection.
• Ureters. The tubes that take urine from each kidney to the bladder are rarely the only site of infection.
• Bladder. An infection in the bladder is also called cystitis or a bladder infection.

Some of the symptoms include:

• Burning pain or a ‘scalding’ sensation when urinating
• Pain above the pubic bone
• Wanting to urinate more often and urgently, if only a few drops
• A feeling that the bladder is still full after urinating
• Blood in the urine.

Most urinary tract infections are caused by bacteria that live in the digestive system. Bacteria that enter the urethra and then the bladder. Women tend to get them more often because their urethra is shorter and closer to the anus than in men.
The most common culprit is a bacterium common to the digestive tract called Escherichia coli (E. coli).
Other micro-organisms, such as mycoplasma and chlamydia, can cause urethritis in both men and women.


Nursing Care Plan for Urinary Tract Infections

Hyperthermia related to infection.
Goal: the patient's body temperature to normal.

Expected outcomes:

• The patient's body temperature is normal.
• Acral feel warm.
• Patients calm / relaxed.

Interventions and Rationale :

Independent

1. Assess increase in body temperature through laboratory tests.
R /: To determine the factors causing an increase in body temperature and to establish further therapy program.

2. Perform a cold or warm compresses on the body.
R /: Warm compresses can enhance vasodilation of blood vessels while cold compress increase vasoconstriction of blood vessels.

Collaboration

3. Implement treatment programs: Management of antipyretics as indicated.
R /: Antipyretics reduce fever.

Observation

4. Monitoring of vital signs.
R /: To know the state of the patient.

5. Monitor fluid intake and output.
R /: Intake and output were less able to stimulate the growth of bacteria in the urinary vesica.

Nursing Care Plan for Bone Cancer

Nursing Care Plan for Bone Cancer

Tumor is the growth of new cells, abnormal, progressive, where the cells never become mature. The incidence of bone tumors when compared with other types of tumors are small, ie less than 1% of all tumors of human body. Malignant tumor, when tumor capable of spreading to other places (able to metastasize) and benign tumors say, if it is not able to metastasize. Lungs, is the organ most frequently seized by child spread of malignant tumors.

There are many different types of cancer. Cancers are usually named based on the type of cell that is affected. For example, lung cancer is caused by cells that are beyond the control of the shape of the lung, and breast cancer by cells that form the breast. A tumor is a collection of abnormal cells which accumulate together. However, not all tumors are cancerous. A tumor can be benign (not cancerous) or malignant (cancerous).

Benign tumors are usually less dangerous and not able to spread to other parts of the body. Malignant tumors are generally more serious and can spread to other areas in the body. The ability of cancer cells to leave their original location and moved to another location in the body is called metastasis. Metastasis can occur with cancer cells enter the blood stream or lymphatic system body to walk to other places in the body.

When cancer cells metastasize to other parts of the body, they are still called by the type of origin of the abnormal cells. For example, if a group of cells into diseased breast cancer and metastasizes to the bones, it is called metastatic breast cancer. Many different types of cancer are able to metastasize to the bones.

The types of the most common cancers that spread to the bones are lung, breast, prostate, thyroid, and kidney. Most of the time, when people have cancer in their bones, it is caused by cancer that has spread from elsewhere in the body to the bones. It is less common to have an original bone cancer, a cancer that arises from cells that make bone. It is important to determine whether the cancer is in the bone from elsewhere or from a cancer of the bone cells. The treatments for cancers that have metastasized to the bone based on the initial type of cancer.

Causes

Bone cancer is caused by a problem with the cells that form bone. More than 2,000 people are diagnosed in the U.S. each year with a bone tumor. Bone tumors occur most commonly in children and adolescents and are less common in the older adults. Cancer involving the bone in adults older are most commonly the result of metastatic spread from another tumor.

Signs and Symptoms

The most common symptom of bone tumors is pain. In most cases, the symptoms become gradually more severe with time. At first, the pain may only be present at night or with activity. Depending on the growth of tumor, those affected may have symptoms for weeks, months, or years before seeking medical advice. In some cases, a mass or lump may be felt in the bone or in the tissues surrounding the bone. Tumors in the leg, causing the patient to walk lame, whereas tumors in the arm cause pain when the arm is used to lift some object. Swelling of the tumor may feel warm and slightly flushed.

Classification

Based on the level of malignancy, there are 3 levels of malignant tumor stages, namely:

1. Stage I, when a low degree of malignancy.
2. Stage II, meaning the tumor has a high degree of malignancy.
3. Stage III, which means the tumor has spread.

Diagnostic tests

1. Physical examination
2. DPL
3. X-Rays
4. Ct-Scan
5. MRI
6. biopsy
7. bone scan

Nursing Diagnosis for Bone Cancer

1. Anxiety related to change in health status.
2. Chronic Pain related to pathologic processes.
3. Imbalanced Nutrition Less Than Body Requirements related to hypermetabolic status with regard to cancer, the consequences of chemotherapy, and radiation effects.
4. Risk for Fluid Volume Excess related to damage to fluid intake.
5. Risk for Infection related to the inadequate immunosuppression, malnutrition and invasive procedures.
6. Risk for Impaired skin integrity related to radiation effects and changes in nutritional status.

Nursing Interventions for Bone Cancer

1. Encourage clients to express feelings and thoughts.
2. Increase a sense of calm and comfortable environment.
3. Determine history of pain.
4. Give a distraction relaxation techniques.
5. Monitor the nutrient intake every day.
6. Control of environmental factors and diet that will be provided.
7. Create a pleasant dining atmosphere.
8. Assess the factors that reduce appetite.
9. Monitor nausea and vomiting.
10. Monitor fluid input and output.
11. Assess vital signs.
12. Encourage increased fluid intake.
13. Increase rest.
14. Emphasize the importance of oral hygiene.
15. Assess the skin as often as possible.
16. Wash with warm water and mild soap.
17. Instruct the client to avoid any skin cream unless there is an indication of physicians.
18. Encourage the use of soft and loose clothing.