Acute Pain and Risk for Injury related to Encephalitis


Nursing Diagnosis for Encephalitis : Acute Pain related to irritation of the brain lining.

Goal :
Patients seen decreases pain / pain control.

Outcomes :
  • Patients can sleep.
  • Saying decrease pain.

Interventions :
1. Try to create a safe and quiet environment.
Rationale : Lowering the reaction to external stimuli or sensitivity to light and encourage patients to rest.

2. Cold compress to the head and a cool cloth on the eye.
Rationale : Can cause vasoconstriction of blood vessels of the brain.

3. Perform active or passive motion exercise in accordance with the conditions of tender and careful.
Rationale : Can help to relax tense muscles and may decrease pain / disconfort.

collaboration :
4. Give analgesics.
Rationale : It may be necessary to decrease pain.


Nursing Diagnosis for Encephalitis : Risk for Injury related to the presence of seizures, altered mental status and decreased level of consciousness.

Goal :
Patients free from injury caused by seizures and loss of consciousness.

1. Monitor spasms in hands, feet, mouth and other facial muscles.
Rationale : Require evaluation in accordance with the appropriate interventions to prevent complications.

2. Prepare a safe environment such as bed boundaries, safety boards, and suction devices have always been close to the patient.
Rationale : Protecting patients when seizures occur.

3. Maintain total bedrest during the acute phase.
Rationale : Reduce the risk of falls / injured if vertigo, sincope, and ataxia occurred.

4. Give appropriate therapy doctors advice.
Rationale : To prevent or reduce seizures.

Ineffective Cerebral Tissue Perfusion related to Encephalitis


Nursing Care Plan for Encephalitis

Nursing Diagnosis : Ineffective Cerebral Tissue Perfusion related to increased intracranial pressure.

Goal :
  • Neurologic status returned to the state before the illness.
  • Increased awareness and sensory function.

Outcomes :
  • Vital signs within normal limits.
  • Headache is reduced.
  • Increased awareness.
  • No signs or loss of increased intracranial pressure.


Interventions :
1. Total bed rest with supine sleeping position without a pillow.
Rationale : Changes in intracranial pressure will be able to mislead the risk for brain herniation.

2. Monitor the status of neurological signs with GCS.
Rationale : Can reduce further brain damage.

3. Monitor vital signs such as BP, pulse, temperature, respiration and caution in systolic hypertension.
Rationale : In normal circumstances autoregulation maintains a state of altered systemic blood pressure to fluctuate. Failure of autoregulation, will lead to cerebral vascular damage that can be manifested by an increase in systolic and diastolic pressure followed by a decrease. While the increase in temperature can describe the course of infection.

4. Monitor intake and output.
Rationale : Hyperthermia can lead to increased IWL and increase the risk of dehydration, especially in patients who are not aware, and nausea were lower intake orally.

5. Help the patient to limit vomiting, coughing. Instruct the patient to exhale when moving or turning in bed.
Rationale : Activity vomiting or coughing can increase intracranial pressure and intra-abdominal. Exhale when moving or changing position can protect themselves from the effects of valsalva's.

Collaboration :

6. Arterial blood gas analysis monitor when needed oxygen administration.
Rationale : The possibility of acidosis is accompanied by the release of oxygen at the cellular level may lead to the occurrence of cerebral ischemic.

7. Give appropriate therapy doctors advice.
Rationale : Given therapy can decrease capillary permeability. Lowering of cerebral edema. Lowering metabolic cells / consumption and seizures.

Imbalanced Nutrition and Knowledge Deficit related to Malaria

Nursing Care Plan for Malaria

Imbalanced Nutrition Less Than Body Requirements related to inadequate food intake ; anorexia ; nausea / vomiting.

Goal :

Nutrients are met.

Outcomes :
Increased nutrient intake.

Intervention :
1. Assess the nutritional history, including the preferred food . Observation and record food intake.
Rational : Keep an eye on caloric intake or lack of quality of food consumption.

2. Give a little to eat, and a little extra food right.
Rational : Gastric dilatation can occur when feeding too quickly after a period of anorexia.

3. Maintain a schedule of regular weighing.
Rational : Keep an eye on the effectiveness of weight loss or nutritional intervention.

4. Discuss preferred by the client and input in a pure diet.
Rational : It can increase input, increase the sense of participation / control.

5. Observe and record the presence of nausea / vomiting , and other symptoms associated.
Rational : GI symptoms may show the effects of anemia ( hypoxia ) in the organ.

6. Collaboration to perform to a dietitian.
Rationale : Need help in planning a diet that meets nutritional needs.


Knowledge Deficit : about the disease, prognosis and treatment needs related to lack of exposure / recall errors of interpretation of information, cognitive limitations.

Interventions :

1. Review the disease process and future expectations.
Rationale : This action provides the knowledge base in which the patient can make a choice.

2. Provide information on drugs, drug interactions, side effects and adherence to the program.
Rationale : Increase understanding and enhance cooperation in healing and reducing recurrence of complications.

3. Discuss the need for proper nutritional intake and balanced.
Rational : That the need for optimal healing and general well-being.

4. Encourage periods of rest and activity scheduled.
Rational : That the energy savings and improve healing.

5. Review the need for personal hygiene and environmental cleanliness.
Rationale : Helps control the exposure environment, by reducing the number of disease-causing there.

6. Identify signs and symptoms that require medical evaluation.
Rationale : Early recognition of the development / recurrence of infection.

7. Emphasize the importance of antibiotic treatment as needed.
Rationale : The use of the prevention of infection.

Disturbed Sleep Pattern related to Osteoarthritis


Nursing Diagnosis for Osteoarthritis : Disturbed Sleep Pattern related to pain

Outcomes :
Clients can meet the needs of rest or sleep.

Independent:
  1. Determine the normal and usual sleep habits and the changes that occur.
  2. Provide a comfortable bed.
  3. Create a new bedtime routine that is included in the old patterns and new environment.
  4. Instruct act of relaxation.
  5. Increase comfort bedtime regimen, such as a warm bath and massage.
  6. Use the bed fence as indicated : if possible lower the bed.
  7. Avoid disturbing the client when the client is asleep, when possible, for example wake for drugs or therapy.

Collaboration :
  1. Give medications as indicated.

Rationale :
  1. Assessing the need for and identify appropriate interventions.
  2. Improving the convenience of sleep and support the physiological / psychological.
  3. When the new routines contain as many aspects of old habits, stress and anxiety -related can be reduced.
  4. Help induce sleep.
  5. Increase the relaxation effect.
  6. Can feel the fear of falling due to changes in the size and height of the bed, place a fence to help change the position.
  7. More uninterrupted sleep creates a feeling of fresh and patients may possibly not be able to go back to sleep if awakened.
  1. May be given to help the patient sleep or rest.

Disturbed Body Image related to Osteoarthritis


Nursing Care Plan for Osteoarthritis

Disturbed Body Image related to changes in the ability to perform common tasks.

Outcomes :
Expressing increased confidence in ability to cope with illness, lifestyle changes and possible limitations.

Interventions :
Independent:
  1. Encourage disclosure about problems regarding the disease process, hope for the future.
  2. Discuss the meaning of the loss / change in patient / significant other. Ascertain how the patient's personal views on the functioning of day-to- day lifestyle.
  3. Discuss the patient's perception of how the people closest to accept limitations.
  4. Acknowledge and accept the feelings of the bereaved, hostile dependency.
  5. Note the behavior of withdrawn, denied or paid much attention to the body / changes.
  6. Arrange limits on maladaptive behavior. Help the patient to identify positive behaviors that can help coping.
  7. Involve the patient in the treatment plan and schedule activities.

Collaboration :
  1. Refer to psychiatric counseling.
  2. Give medicines as directed.

Rationale :
  1. Give a chance to identify a fear / upset face it directly.
  2. Identify how the disease affects self-perception and interaction with others will determine the need for further intervention or counseling.
  3. Verbal cues / nonverbal people nearby can have a major influence on how the patient views himself.
  4. Pain is exhausting, and feelings of anger, hostility common.
  5. Can indicate emotional or maladaptive method, requiring further intervention or psychological support.
  6. Helping patients maintain self-control can increase feelings of self-esteem.
  7. Increase feelings of competence / self-esteem, encourage independence, and encourage participation and therapy.
  8. Patient / significant other may need support for dealing with long-term process / disability.
  9. May be required at the time of the advent of the Great Depression until patients develop effective coping skills.

Activity Intolerance and Risk for Injury related to Osteoarthritis

Nursing Care Plan for Osteoarthritis


Nursing Diagnosis for Osteoarthritis : Activity Intolerance related to changes in muscle.

Outcomes :
Clients are able to participate in the desired activity.

Interventions :
  • Maintain bed rest / sit down if necessary.
  • Help move with minimal assistance.
  • Encourage clients maintain an upright posture, sitting height, standing and walking.
  • Provide a safe environment and recommends to use a walker.
  • Give as indicated drugs such as steroids.
Rationale :
  • To prevent fatigue and maintains strength.
  • Improve joint function, muscle strength and general stamina.
  • Maximizing the function of joints and maintain mobility.
  • Avoiding injuries caused by accidents such as falls.
  • To suppress acute systemic inflammation.

Nursing Diagnosis for Osteoarthritis : Risk for Injury related to decrease in bone function.

Outcomes :
Clients can maintain physical safety.

Interventions :
  • Control of the patient's environment : Getting rid of the obvious dangers, reducing potential injury from falling while sleeping for example using a buffer bed, try to position the lower bed, night lighting ready to use call lights.
  • Allow maximum independence and freedom to provide freedom in a safe environment, avoid the use of restrain, when patients daydreaming distract rather than startled.

Rationale :
  • Hazard-free environment that will reduce the risk of injury and relieve families of the constant concerns.
  • This will give the patient autonomy, can restrain the increase of agitation, if the shock will increase anxiety.

Pain (acute / chronic) related to Osteoarthritis


Nursing Care Plan for Osteoarthritis

Pain (acute / chronic) related to tissue distension by accumulation of fluid / inflammation, joint destruction.

Outocomes :
  • Showed pain control.
  • The client looks relaxed, can sleep / rest and participate in activities.
  • Following therapy program.
  • Combining the skills of relaxation and entertainment activities into the program of pain control.

Interventions :
  1. Assess complaints of pain, note the location and intensity of pain (scale 0-10), note the factors that accelerate and signs of pain.
  2. Give a hard mattress, small pillows. Elevate the bed linens as needed.
  3. Let the patient take a comfortable position when sleeping or sitting in a chair. Increase bed rest as indicated.
  4. Encourage patients to frequently change positions. Help the patient to move in bed, prop sore joints above and below, avoid jerky movements.
  5. Encourage patients to a warm bath or shower to wake-up time. Provide a warm washcloth to compress the affected joints several times a day. Monitor the temperature of the water compresses , water bath.
  6. Give a gentle massage.
  7. Collaboration : Give medication before activity or exercise that is planned according to the instructions as acetyl salicylate.


Rationale :
  1. Assist in determining the need for and effectiveness of pain management programs.
  2. Soft mattress, great pillows will prevent the maintenance of proper body alignment, placing setres the diseased joints. Elevation of the bed linens pressure on inflamed joints / pain.
  3. In severe disease, bed rest may be necessary to limit joint pain or injury.
  4. Preventing the occurrence of general fatigue and joint stiffness. Stabilize the joint, reduce movement / pain in the joints.
  5. Heat increases muscle relaxation and mobility, decrease pain and stiffness in the morning release. The sensitivity of the heat can be removed and dermal wounds can be healed.
  6. Increasing relaxation / reduce muscle tension.
  7. Increase relaxation, reduce muscle tension, ease to participate in therapy.

NANDA Nursing