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Care Plan for Mitral Stenosis : Assessment and 6 Nursing Diagnosis

Nursing Care Plan for Mitral Stenosis 

Mitral stenosis (MS) is the obstruction of the mitral valve that causes constriction of blood flow to the ventricles. Patients with Mitral Stenosis typically have thickened mitral leaflets, commissura are fused, and the chordae tendineae were thickened and shortened. Transverse diameter of the heart usually within normal limits, but calcification of the mitral valve and left atrial enlargement can be seen.

Assessment
  1. Main Complaint: patients with mitral stenosis usually complain of shortness of breath, cyanosis and coughing.
  2. History of present illness: Clients are usually taken to hospital after shortness of breath, cyanosis or coughing is accompanied by high fever / no.
  3. Past medical history: The client had suffered from rheumatic fever disease, SLE (Systemic Lupus Erithematosus), RA (rheumatoid Rhemautoid), myxoma (a benign tumor in the left atrium).
  4. The family medical history: no hereditary factors that influence the occurrence of mitral stenosis.


Review of System
  1. B1 (Breath): Shortness / respiration increases, low tone at the apex by using a bell on his side to the left, shortness of breath and fatigue, cough, orthopnea in venous congestion there.
  2. B2 (Blood): an increase in the jugular vein, leg edema, atrial arrhythmias such as atrial fibrillation (rapid heart rate and irregular), hemoptysis, embolism and thrombosis, strength weakened pulse, tachycardia, peripheral edema (start happening right heart failure), BJ 1 loud systolic murmur, palpitations, hemoptysis, apical diastolic murmur.
  3. B3 (Brain): chest and abdominal pain.
  4. B4 (Bladder): excess fluid imbalance, oliguric.
  5. B5 (Bowel): dysphagia, nausea, vomiting, no appetite.
  6. B6 (Bone): weakness, sweating, tired .


Psychosocial Assessment
  1. Shortness of breath affect the interaction.
  2. Limited activity.
  3. Afraid of surgery.
  4. Stress due to the condition of the disease with a poor prognosis.

Nursing Diagnosis:
  1. Impaired tissue perfusion r / t decrease in peripheral blood circulation; cessation of arterial-venous flow; decrease in activity.
  2. Risk for fluid volume overload r / t the displacement pressure in the pulmonary venous congestive; Decreased perfusion of organs (kidney); increased retention of sodium / water; hydrostatic pressure increase or decrease in plasma proteins (absorbing fluid in the interstitial area / network).
  3. Ineffective breathing pattern r / t permeation fluid, pulmonary congestion secondary to changes in alveolar capillary membrane and fluid retention intertestial.
  4. Impaired gas exchange r / t changes in capillary-alveolar membrane (displacement of fluid into the interstitial area / alveoli).
  5. Activity intolerance r / t decreased cardiac output to the tissue.
  6. Acute pain r / t strain the left atrium.

Pediatric Nursing Care Plan - Asthma in Children

Nursing Care Plan for Asthma

Asthma is the leading cause of chronic disease in children, which causes the majority of school days lost due to chronic diseases. Approximately 80-90% of children with asthma get the first symptoms before the age of 4-5 years. At one time during the child will have symptoms and signs in accordance with asthma.

Severe asthma is difficult to predict. Most children who suffer a fraction will suffer severe asthma that is difficult to treat, usually more is chronic rather than seasonal. Which causes helplessness and significantly affect day-to-day school, play activities, and daily functioning. It is an unpleasant thing when in times of play and activity, children disturbed because of illness. This of course requires special attention in the form of care, treatment and prevention.

Therefore asthma require special handling, especially in children who are always filled with joy in the days of play and activity in everyday life, with the involvement of health professionals from a variety of multidisciplinary fields. In nursing care, nurses have a role as professionals that act provides nursing care, health education to parents, provide information on the definition, signs and symptoms, and prevention independently or collaboratively with various parties.


Pediatric Nursing Care Plans - Asthma in Children
Definition

Asthma is a disease with a characteristic increase in the trachea and bronchi reaction by various originators accompanied by the onset of constriction outside the lower respiratory tract that can vary the degree spontaneously or with treatment.


Cause

Extrinsic factors : Found in a small number of adult patients and is caused by allergens that are known because of the sensitivity of individual, usually a protein, in the form of pollen that life, animal fuzz, lint or more rarely to food such as milk or chocolate, pollution.
Intrinsic factor: This factor is often not found the trigger factors that clear. Nonspefisik factors, such as the common cold, physical or emotional exercise can trigger an asthma attack. This intrinsic asthma is usually due to heredity and also often develop after the age of 40 years. With attacks arising after nasal or sinus infection at trakeobronchial branching.


Signs and Symptoms

The classic symptoms of asthma consist of cough, breathlessness and wheezing and most patients with chest pain. These symptoms do not always occur together, so that there is some degree of asthmatics as follows:

Level I: asthmatics clinically normal. Asthma symptoms occur when there is a trigger factor.

Level II: asthmatics without complaint and without abnormalities on physical examination but lung function showed signs of airway obstruction.

Level III: asthmatics without classes but on physical examination and lung function showed airway obstruction.

Level IV: asthmatics are most often found complaining of shortness of breath, coughing and wheezing.
On physical examination and spirometry will find airway obstruction. In severe asthma attack symptoms include: Compression respirator muscles, especially the muscles of the sternum, cyanosis, silent chest, disturbance of consciousness, patient looked tired, chest hyperinflation and tachycardia.

Level V: status asthmaticus, namely; Severe acute asthma attacks are refrater while on treatment directly used.

Nursing Care Plan for Pulmonary Tuberculosis (Gordon's Functional Health Pattern)

Pulmonary Tuberculosis - Definition, Etiology, Pathophysiology, Clinical Manifestations, Diagnostic Eexamination, Prevention, Management / Treatment,  Assessment and  Gordon's Functional Health Patterns

Definition
Tuberculosis is a contagious infectious disease caused by Mycobacterium tuberculosis, an acid-resistant aerobic bacillus transmitted through the air (airborne). In almost all cases of tuberculosis infection acquired through inhalation of small particles of bacteria (approximately 1-5 mm).


Etiology
The cause of pulmonary tuberculosis are germs (bacteria) that can only be seen with a microscope, the mycobacterium tuberculosis. Mycobacterial are aerobic bacteria, shaped stones that form spores.


Pathophysiology
Causes of pulmonary tuberculosis occurs because germs coughed out into droplet nuclei in the air. The infectious particles can settle in free air for 1-2 hours, depending on the presence or absence of ultraviolet light, poor ventilation and moisture. In a humid atmosphere and dark germs can hold for days to months. BCG infection particle is inhaled by healthy people, it will stick to the airway or lungs. Germs will be encountered first by neutrophils, then just by macrophages. Most of these particles will die or cleared by macrophages out of tracheal bronchial branch, along with the movement of cilia in the secretions.
When germs settle in the lung tissue, it will multiply in the cytoplasm of macrophages. Here germs can be brought into other organs. If, entered into the pulmonary artery occurs spreading to all parts of the lungs become miliary tuberculosis.
Of primary nest will arise inflammation hilar lymph channels leading, and also followed by enlarged lymph nodes virus. All this process takes 3-8 weeks.


Clinical Manifestations

Clinical symptoms of tuberculosis can be divided into two groups, namely respiratory symptoms and systemic symptoms.
1. Respiratory symptoms
  • Cough for more than 3 weeks.
  • Coughing up blood.
  • Chest pain.
2. Systemic symptoms
  • Fever.
  • Other systemic symptoms: malaise, night sweats, anorexia and weight loss.

Diagnostic Examination
  • Sputum culture: positive for mycobacterium tuberculosis.
  • Ziehl-Neelsen: positive for acid fast bacilli.
  • Skin test (PPD, Mantoux, Pieces volumer) shows: past infection and the presence of anti-bodies, but does not necessarily reflect active disease.
  • X-ray of the thorax: early lesions showed infiltration in the lung area above.
  • Histology or tissue culture: positive for mycobacterium tuberculosis.
  • Examination of lung function: decreased vital capacity, an increase in dead space, increasing the ratio of residual air and total lung capacity, and decreased oxygen saturation secondary to parenchymal infiltration or fibrosis, loss of lung tissue and pleural disease.
Management / Treatment

Assessment of treatment success was based on the results of bacteriological and clinical examination. Good cure pulmonary tuberculosis will notice sputum smear (-), an improvement of radiology and relieve symptoms.


Complication
  • Coughing up blood.
  • Pneumothorax.
  • Crushed lungs.
  • Respiratory failure.
  • Heart failure.
  • Pleural effusion.
Prevention
  • Can be done by;
  • BCG vaccination in infants and children.
  • Preventive therapy.
  • Diagnosis and treatment of tuberculosis treatment (+) to prevent transmission.


Assessment

1. Identity of the patient
Consisting of name, age, gender, religion, and others.

2. Health History
The main complaint: Most cases encountered the client in with complaints of cough more than 3 weeks.
The main complaint history: Usually cough experienced more than 1 week accompanied by an increase in body temperature, decreased appetite and body weakness.


Gordon's Functional Health Patterns

1. Health Perception and Management
View of the patient about the disease and how to deal with patients who carried the disease.

2. Nutritional metabolic
The ability of patients to consume food has decreased due to the lack of appetite / malaise.

3. Elimination
Patients with pulmonary TB is rare impaired bowel and bladder elimination.

4. Activity exercise
Usually, the patient experienced a decrease in activity associated with body weakness experienced.

5. Sleep - rest
Rest and sleep is often disturbed due to cough experienced at night.

6. Cognitive-perceptual
Memory pulmonary TB patients mostly found not impaired.

7. Self perception / self concept
Feelings receive from patients with the situation, most patients are not impaired self-concept.

8. Role Relationship
Changes in the pattern of relations role in responsibilities or changes in physical capacity to perform the role.

9. Se-uality reproductive
The patient's ability to perform in accordance with the gender roles. Most patients do not do se-ual because of the weakness of the body.

10. Coping-stress tolerance
Defense mechanism used by patients is to seek help from others.

11. Value-Belief Pattern
The religion of the patient and patient compliance in performing religious teachings usually not impaired in patients sisitem values and beliefs.

Meningitis - Nursing Implementation, Evaluation and Discharge Planning


Nursing Implementation

Implementation is the initiative of a plan of action to achieve a specific goal. (Nursalam, 2001)

This stage is the fourth stage in the nursing process, therefore implementation began after an action plan formulated and refer to the appropriate scale plan of action is urgent and not urgent.

In the implementation of the action there are three stages that must be passed, namely preparation, planning, and documentation (Nursalam, 2001 quoted from Griffit 1968).

1. Preparation phase, include:
  • Review anticipation nursing actions.
  • Analyze the knowledge and skills required.
  • Knowing the complications that may arise.
  • Preparation tool.
  • Preparation of a conducive environment.
  • Identify the legal and ethical aspects.
2. Intervention phase, include:
  • Independent: actions taken by nurses without instructions or orders of doctors and other health care team.
  • Interdependent: nurse actions that require cooperation with other health team (nutrition, doctors, laboratories, and others).
  • Dependent: associated with medical treatment or indicate where medical treatment is done.
3. Documentation phase
  • Is a complete and accurate record of the actions that have been implemented. In the implementation of nursing care actions on the client, the nurse can act as executor of nursing, give support, educators, advocacy, and recording / data collection.



Evaluation

Evaluation is one of the planned and systematic comparison of the client's health status (Griffit and Cristensen, 1986). While Ignativicius and Bayne 1994 said evaluation is an intellectual action to complete the nursing process that indicates how far nursing diagnosis, plan of action and its implementation has been achieved.

Evaluation consists of two types of formative evaluation and summative evaluation. Formative evaluation is also called the evaluation process, the evaluation of short-term, or evaluation runs, where the evaluation carried out immediately after nursing actions performed until the goal is reached. While summative evaluation is called the evaluation result, the final evaluation, evaluation of the long-term. The evaluation was conducted at the end of the plenary nursing actions performed and become a method of monitoring the quality and efficiency preformance given action. This evaluation forms typically use the format "SOAP" (Nursalam, 2001).

The purpose of evaluation is to regain feedback nursing plan, the value and improve the quality of nursing care through the comparison of pre-determined standards.


Discharge Planning

Plan provided to clients and families are as follows:
  1. As health professionals, we provide an explanation to the client's family, when his son raised signs and symptoms such as unconsciousness, seizures, fever and slow pulse to immediately go to the nearest health center or directly to a large hospital.
  2. Instruct the client to comply with the treatment regimen required to take medication appropriate screening and follow-up report.
  3. Advise the client to participate in preventive measures, eg encouraging the individuals in close contact to report themselves for examination.
  4. Increasing consumption of nutrients and protein and consume vitamins that increase body strength.
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