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Nursing Care Plan related to Infection

Assessment, Nursing Diagnosis, Interventions, Implementationa and Evaluation


Nurses assess the following matters:

1 Status defense mechanisms

The primary defense is not adequacy (skin / mucosal damage, tissue trauma, obstruction of lymph flow, peristaltic disorders, decreased mobility).
Secondary defense is not adequacy (decrease in Hb, WBC suppression, suppression of the inflammatory response, leukopenia).

2 Vulnerability client
  • Age : Babies have a weak defense against infection, at birth have antibodies from the mother, while the immune system is still immature. As the child grows, the more mature the immune system, but the baby is still susceptible to the organism causes fever, intestinal infections, and other infectious diseases (mumps and measles). Early adult immune system has given the defense the bacteria invade. In old age, because the function and decreased organ, the immune system is also changing.
  • Nutritional status : Reduction of the intake of protein and other nutrients such as carbohydrates and cause a decrease in the body's defenses. Nurses assess the dietary intake of the client and the client's ability to consume food (there is no interruption in the process of swallowing or digestive system).
  • Stress : The body responds to emotional or physical stess through the general adaptation syndrome. If stess continues, causing high levels of cortisone yan decreased immune system.
  • Heredity : Certain hereditary disorders interfere with an individual's defense against infection.
  • Disease process : Clients who are sick in the immune system, especially the risk of infection. Clients who are experiencing complex illness (complications) higher risk of infection.
  • Medical therapy : Some drugs and medical therapies affect the immune system. Nurses need to assess the client's drugs consumed.
3 Clinical appearance

Signs and symptoms of infection can be either local or systemic infection. Nurses need to examine the sign that appears on the client.

4 Laboratory data

The nurse examines the client's laboratory results.

Nursing Diagnosis related to Infection
  1. Risk for infection r / t impaired immunity.
  2. Risk for infection r / t tissue damage.
  3. Risk for injury r / t impaired immunity.
  4. Impaired skin integrity r / t interruption of circulation
  5. Imbalanced nutrition less than body requirements r / t poor dietary habits that
  6. Imbalanced nutrition less than body requirements r / t GI dysfunction.


The general objective:
Prevention of exposure to infectious organisms.
Monitor and reduce the spread of infection.
Maintain resistance to infection.
Clients and families learn about infection control.

  • Prevention of disease (destroying the reservoir of infection, control the exit and entrance portals, avoiding the transmission of action, preventing bacteria find a place to grow).
  • Measures of acute treatment (administration of appropriate antibiotics in the treatment and other measures).

Control of infectious agents:
  • Cleaning. Throw out all foreign material such as dirt and organic material of an object.
  • Disinfection. A process to destroy bacteria, but the spores
  • Sterilization. Destruction and destruction of all microorganisms, including spores.

Reservoir control
  • Bathe regularly.
  • Changing bandages wet or dirty.
  • Contaminated objects, discarded at the right place.
  • Contaminated needles, discarded at the right place.
  • Surgical wounds treated correctly.
  • Nursing bottle and bag drainage.
  • Keep the solution in a bottle.

Infection control:
  • Wash hands.
  • Avoiding the use of the same tool in some patients.
  • Avoid touching dirty objects nurse's uniform.
  • Instruct visitors to wash their hands before visiting a client.
  • Familiarize client to wash hands.
Control of the portal of entry
  • Maintaining the integrity of the skin and mucous membranes.
  • Skin is kept moist.
  • Setting position.
  • Perform oral hygiene.
  • Be careful within taking care of the wound.
  • Be careful in removing medical devices disposable.
Protection of the vulnerable host:
  • Isolation.
  • Maintain nutritional status.
  • Maintain personal hygiene.
  • Provide social support to clients who were isolated.
  • Protective environment.
Protection of workers:
  • Gown.
  • Mask.
  • Gloves.
  • Protective goggles.
  • Collection of specimens.
  • Goods or linen wrap.

  • Evaluation of the action / implementation has been done, if the action can not resolve the problem then forwarded nursing actions, if the problem is resolved, the action was stopped.
  • For example, do not forget to wash your hands before and after examining patients. Not use the tool in a row in some patients without first properly cleaned after use on a patient. Bathing and cleaning the patient should not be considered routine work that must be completed as soon as possible, but should be done with full responsibility for the safety of the patient against the threat of nosocomial infections.
  • To participate prevent fungal and bacterial resistance to antibiotics, use of antibiotics in a responsible manner, ie only against susceptible bacteria and fungi, and in sufficient quantity and under the supervision of a physician.
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Impaired Physical Mobility Care Plan

Nursing Care Plan for Impaired Physical Mobility

  • Mobilization is an irregular movement, organized and orderly.
  • Mobilization is an individual's ability to move freely, easily and regularly with the aim to meet the needs of the activity in order to maintain health.
  • Mobilization is the ability to move freely. (Musrifatul Uliyah and A. Aziz A. H., 2008; 10)
  • Mobilization is the ability to move freely and regularly to meet the needs of a healthy self-reliance and mobilization which refers to the inability of a person to move freely. (Perry and Potter, 1994)

Types of Mobility

Full mobility

Is a condition in which a person's ability to move fully and freely in order to make social interaction and run the day-to-day role. Full mobility is a function of the motor nerves, sensory voluntary and to be able to control all areas of a person's body.

Partially mobility

A person's ability to move with clear boundaries and are not able to move freely because it is influenced by the motor and sensory neurological disorders in areas of the body.
Mobilization of this portion is divided into two parts, namely:
  • Temporary part time mobility, an individual's ability to move with temporary restrictions. This can be caused by trauma to the musculoskeletal system such as reversible on any dislocation of joints and bones.
  • Permanent part time mobility, an individual's ability to move with boundaries that are fixed. It is caused by damage to the nervous system that is reversible. For example: the occurrence of hemiplegia due to stroke, spinal cord injury praplegi for and specific to poliolemitis due to disruption of sensory and motor nervous system.

  • Lifestyle
  • Process of disease / injury
  • Culture
  • Energy levels
  • Age and developmental status
  • Activity intolerance
  • Neuromuscular disorders
  • Muscular disorders

Signs and Symptoms
1. Joint contracture
Caused by disuse, muscle atrophy and neural approaches.
2. Changes in urinary elimination
Urinary elimination is changing due to the immobilization of the patient in the upright position, urine flows out of the renal pelvis and into the ureter and bladder due to the force of gravity.
3. Changes in integument system
Pressure sores are caused by tissue ischemia and anorexia. Depressed tissue, blood forming and strong constriction of the blood vessels due persistem pressure on the skin and under the skin structure so that cellular respiration becomes impaired and cell death.
4. Changes in metabolic
When injury or stress occur, endocrine system triggers a series of responses that aim to maintain blood pressure and maintain life.
5. Changes in the musculoskeletal system
Limitations affect the mobilization of clients through loss of muscle endurance, decreased muscle mass atrophy and decreased stability.
6. Changes in the respiratory system
Clients with postoperative immobilization and an increased risk of complications in the lungs.

Benefits Mobilization
1. Patients feel healthier and stronger with early ambulation.
2. Reduce the pain so the patient feels healthy.
3. Helps accelerate the body's organs to work as before.
4. Mobilization allows us to quickly teach the patient to be able to care for himself.
5. Prevent the occurrence of thrombosis and thromboembolism.
6. Maintaining the flexibility of the bones and joints also increases muscle strength.

Clinical Symptoms / Problems of Mobilization
1. Diseases of the nervous system.
2. muscular dystrophy.
3. Tumors of the central nervous system.
4. Increase in intra-cranial.
5. connective tissue disease.

ADL Scale (Activity Daily Living)
0: Patients can stand.
1: Patients need help / minimal equipment.
2: Patients requiring assistance are being / with supervision.
3: Patients requiring special assistance and the needed tools.
4: It depends totally on the provision of care.

Things to consider in mobilization

Usually do assessments on time before mobilization and after mobilization like the signs that will be studied in intolerance among other activities (Goldon, 1976)

1 Assist the patient sitting up in bed
This action is one way of maintaining patient mobility.
Maintaining comfort.
Maintain tolerance to activity.

2 Adjust the position of the patient in bed
a. Fowler position is the position of the patient half sitting / sitting
Maintaining comfort
Facilitate respiratory function

b. Sim's position is the patient lying on his side up to the right or to the left
Blood circulation to the brain.
Provide comfort.
Doing an enema.
Giving drugs per rectum.
To examine the anal area.

c. Trendelenburg position is to place the patient in bed with the head lower than the feet.
Purpose: to improve blood circulation.

d. Dorsal recumbent position is the position of the patient is placed in the supine position with flexed knees on the bed
Genetalia area treatment.
Examination genetalia.
The position on the delivery process.

e. Lithotomy position is the position of the patient is placed in the supine position with both legs lifted and pulled to the top of the abdomen.
Examination genetalia.
The delivery process.
Installation of contraception.

f. Genupectoral position, is the position with both legs bent and torso attached to the top of the bed.
Transporting patients to the tdiur / to wheelchair
Doing skeletal muscles to prevent contractures.
Maintain patient comfort.
Maintaining self-control patients.
Transferring patients for examination.

Helping the patient to walk
Activity tolerance.
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Primary and Secondary Assessment for Myocardial Infarction

Nursing Care Plan for Acute Myocardial Infarction

Primary Assessment of Myocardial Infarction
1. Airways
  • Blockage or accumulation of secretions.
  • Wheezing or crackles.
2 Breathing
  • Congested with light activity or rest.
  • RR is more than 24 times / minute, shallow irregular rhythm.
  • Ronchi, crackles.
  • Expansion of the chest is not full.
  • The use of accessory muscles of breath.
3 Circulation
  • Weak pulse, irregular.
  • Tachycardia.
  • Blood pressure increases / decreases.
  • Edema.
  • Restless.
  • Cold acral.
  • Pale skin, cyanosis.
  • Decreased urine output.

Secondary Assessment of Myocardial Infarction
1 Activity
  • Symptoms: Weakness, fatigue, can not sleep, sedentary lifestyles, irregular exercise schedule.
  • Signs: Tachycardia, dyspnea at rest or activity.
2 Circulation
  • Symptoms: history of previous AMI, coronary artery disease, blood pressure problems, diabetes mellitus.
  • Signs: Blood pressure; can be normal / up / down. Postural changes recorded from sleeping to sitting or standing. pulse; can be normal, full or not strong or weak / strong quality with slow capillary refill, irregular (dysrhythmias). Heart sounds; Extra heart sounds: S3 or S4 may indicate heart failure or decreased ventricular kontraktilits or complaint. murmur; when there is a demonstrated failure of valves or heart muscle dysfunction. friction; suspected pericarditis. Heart rhythm can be regular or irregular. edema; juguler venous distention, edema dependent, peripheral, generalized edema, there may be crackles with heart failure or ventricular. color; Pallor or cyanosis, flat nails, mukossa membranes or lips.
3 Ego integrity
  • Symptoms: Denying important symptoms or any condition fear of dying, feeling the end is near, angry at the disease or treatment, worry about finances, work, family.
  • Signs: turned, denial, anxiety, lack of eye contact, anxiety, anger, attack behavior, focus on self, pain coma.
4 Elimination
  • Signs: normal, decreased bowel sounds.
5. Food or fluid
  • Symptoms: nausea, anorexia, belching, heartburn or a burning sensation.
  • Signs: decreased skin turgor, dry skin, sweating, vomiting, weight changes.
6 Hygiene
  • Symptoms or signs: lesulitan perform maintenance tasks.
7 Neurosensory
  • Symptoms: dizziness, throbbing during sleep or when you wake up (sitting or resting)
  • Signs: mental changes, weakness
8 Pain or discomfort
  • Symptoms: sudden onset of chest pain (may or may not be related to the activity), not relieved by rest or nitroglycerin (although mostly in and visceral pain). Location: A typical on the anterior chest, substernal, precordial, can spread to the hands, ranhang, face. No specific location such as epigastric, elbows, jaw, abdomen, back, neck. Quality: "Crushing", narrowed, weight, sedentary, depressed. Intensity: Normally 10 (on a scale of 1 -10), may experience the worst pain ever experienced.
  • Note: there may be no pain in postoperative patients, diabetes mellitus, hypertension, elderly.
9 Breathing:
  • Symptoms: dyspnea on exertion or at rest, nocturnal dyspnea, cough with or without sputum production, history of smoking, chronic respiratory disease.
  • Signs: increased frequency of breathing, shortness of breath / strong, pale, cyanosis, breath sounds (clean, krekles, wheezing), sputum.
10. Social Interaction
  • Symptoms: Stress, Difficulty coping with a stressor such as: disease, treatment in hospital.
  • Signs:. Difficulty rest in peace, too emotional response (constantly angry, scared), withdrew.

Nursing Care Plan for Cardiovascular Disease : Myocardial Infarction
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Nursing Care Plan for Cardiovascular Disease : Myocardial Infarction

Nursing Care Plan for Myocardial Infarction


According to Brunner & Suddarth, 2002 myocardial infarction refers to the process of destruction of heart tissue due to inadequate blood supply so that coronary blood flow is reduced.
While understanding according Suyono 1999 acute myocardial infarction is myocardial necrosis due to blood flow to the heart muscle is interrupted.


According to Kasuari, 2002 there were some etiology / cause of acute myocardial infarction, namely:
1) The cause:
a) Reduced myocardial oxygen supply caused by three factors:
  • Vascular factors: Atherosclerosis, spasm, arteritis.
  • Circulation factors: hypotension, aortic stenosis, insufficiency.
  • Blood factors: anemia, hypoxemia, polycythemia.
b) Cardiac output increased:
  • Excessive activity.
  • Eating too much.
  • Emotions.
  • Hyperthyroidism.
c) Increased myocardial oxygen demand, at:
  • Myocardial damage.
  • Myocardial hypertrophy.
  • Diastolic hypertension.

2) Predisposing factors
a) Biological risk factors that can not be changed:
  • Age over 40 years.
  • Gender: high incidence in men, whereas in women increases after menopause.
  • Heredity.
  • Race: the incidence is higher in blacks.
b) Risk factors that can be changed:
  • Major: Hypertension, Hyperlipidemia, Obesity, Diabetes, Smoking, Diet: high in saturated fat, high in calories.
  • Minor: Personality type A (aggressive, ambitious, emotional, competitive), excessive psychological stress, physical inactivity.

Signs and Symptoms of Myocardial Infarction
1 Pain :
  • The main symptom is chest pain that occurs suddenly and constantly not subside, usually felt over the lower sternal region and upper abdomen.
  • Increased severity of pain can persist until the pain becomes unbearable.
  • Pain is very sick, like a punctured-pin that can spread to the shoulder and continues down to the arm (usually the left arm).
  • The pain began spontaneously (not occur after activity or emotional disturbance), persist for several hours or days, and not relieved by rest or nitroglycerin assistance.
  • The pain may spread to the direction of the jaw and neck.
  • Pain is often accompanied by shortness of breath, pale, cold, severe diaphoresis, dizziness or head was floating, and nausea and vomiting.
  • Patients with diabetes mellitus will not experience severe pain because of neuropathy that accompanies diabetes can interfere neuroreseptord.

2 Laboratory
Cardiac enzyme tests:
  • CPK-MB / CPK, Isoenzymes were found in heart muscle increased between 4-6 hours, peaks within 12-24 hours, returning to normal within 36-48 hours.
  • LDH / HBDH, Increased within 12-24 hours dam takes a long time to return to normal
  • AST / SGOT, Increased (less real / special) occurs within 6-12 hours, peaking within 24 hours, returning to normal within 3 or 4 days.

  • ECG changes that occurred in the early phase of high T waves and symmetrical. After this there is ST segment elevation. Change happens then is the wave Q / QS indicating the presence of necrosis.

Test and Diagnosis
  1. ECG. To determine the function of the heart. It will be found an inverted T wave, ST depression, pathological Q.
  2. Cardiac enzymes. CPKMB, LDH, AST.
  3. Electrolytes. Imbalance can affect conduction and contractility, such as hypokalemia, hyperkalemia.
  4. White blood cells. Leukocytes (10000-20000) usually appears on day 2 after AMI associated with inflammatory processes.
  5. Sedimentation velocity. Increased on day 2 and 3 after AMI, indicating inflammation.
  6. Chemistry. May be normal, depending on the function or organ perfusion abnormalities acute or chronic
  7. Blood gas analysis. Hypoksia or process can be demonstrated acute or chronic lung disease.
  8. Serum cholesterol or triglycerides. Increased, indicating arteriosclerosis as a cause of IMA.
  9. Chest x-ray. May be normal or show an enlarged heart is suspected CHF or ventricular aneurysm.
  10. Echocardiogram. Performed to determine the dimensions of the foyer, ventricular wall motion or valves and valve configurations or functionality.
  11. Nuclear imaging tests. a. Thallium: evaluating myocardial blood flow and myocardial cell status such as the location or extent of AMI. b. Technetium: collected in ischemic cells around the necrotic area.
  12. Blood imaging of the heart (MUGA). Evaluating appearance special and general ventricles, regional wall motion and ejection fraction (blood flow).
  13. Coronary angiography. Illustrates the narrowing or blockage of the coronary arteries. Usually done in conjunction with pressure measurements porch and assess left ventricular function (ejection fraction). The procedure is not always done in the phase of AMI, except approaching emergency heart surgery or angioplasty.
  14. Nuclear magnetic resonance (NMR), allows visualization of blood flow, cardiac or valve ventricular porch, lesivaskuler, plaque formation, areas of necrosis or infarction and blood clots.
  15. Exercise stress test, Determining the cardiovascular response to the activities or often done in conjunction with thallium imaging in the healing phase.

Acute Pain - Nursing Care Plan Myocardial Infarction
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