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Nursing Interventions for Conjunctivitis : Disturbed Sensory Perception (Visual)

Nursing Care Plan for Conjunctivitis - Nursing Diagnosis : Disturbed Sensory Perception (Visual)


Definition

Conjunctivitis is an inflammation of the conjunctiva by viruses, bacteria, chlamydia, allergies, trauma (sunburn) (Barbara C. Long, 1996).

Conjunctivitis is inflammation of the conjunctiva and is characterized by swelling and exudates, eyes appear red so often called red-eye diseases (Brunner and suddarth, 2001).


Etiology
  • Can be infectious (bacterial, chlamydia, viruses, fungi, parasites).
  • Immunological (allergies).
  • Irritative (chemical, electrical temperature, radiation, for example due to ultraviolet light).

Clinical Manifestations:
Signs and symptoms of conjunctivitis, could include:
  • Hyperemia (redness).
  • Liquid.
  • Edema.
  • Spending tears.
  • Itching on the cornea.
  • Burning / taste scratched.
  • Feels like a foreign object.

Nursing Diagnosis : Disturbed Sensory Perception (Visual) related to damage to the cornea

The expected goals:
Improve visual acuity within the limits of individual situations.

Intervention :
1. Determine acuity, note whether one or both eyes are involved.
Rasionali: individual needs and choice of interventions varied causes vision loss occurs slowly and progressively, if bilateral, each eye may progress at different rates, however, usually only one eye fixed per procedure.

2. Orient the patient on the environment, staff, other people in the area.
Rasionali: Provides increased comfort and familiarity, lowers anxiety and disorientation postoperatively (Marilynn E. Doenges, 2000).

Decreased Cardiac Output and Ineffective Cerebral Tissue Perfusion related to Syncope

 |  in Syncope at  10:03 AM
Nursing Care Plan for Syncope


Definition of Syncope

Syncope is a body mechanism to anticipate changes in the blood supply to the brain and usually occurs suddenly and briefly or loss of consciousness and postural body strength and the ability to stand, because of the reduction of blood flow to the brain. Fainting, "blacking out", or syncope can also be interpreted as a temporary loss of consciousness followed by the return of full alertness.

Syncope is a final establishment of the body in maintaining a lack of substances important for supply to the brain such as oxygen and other substances (glucose) from the damage that could be permanent.


Causes of Syncope

Factors that can trigger syncope is divided into two, namely: psychogenic factors (fear, tension, emotional stress, severe pain that occurs suddenly and unexpectedly and fear the sight of blood or medical equipment such as syringes) and non-psychogenic factors (upright sitting position, hunger, poor physical condition, and the environment is hot, humid and dense).

The most frequent cause of syncope can be divided into several sections such as:

1. Cardiac (Heart) and blood vessels
  • Heart Blockages: Disturbances in the heart can be caused by a blockage (obstruction) in the heart of this blockage can be caused by heart valve disorders, tumors and enlargement of the heart muscle and heart diseases.
  • Heart electricity: Electrical disorders of the heart, causing arrhythmia and cardiac pulsation frequency so that the volume of blood pumped to the body and to the brain will also be reduced.
  • Vertebrobasilar system: The narrowing of the blood vessels due to age, smoking, high blood pressure, high cholesterol, and diabetes. Vertebrobasilar system is risky for the narrowing, and if there is a temporary interruption in blood flow to the midbrain and reticular activating system, fainting or syncope may occur.

2. Innervation
  • Vasovagal syncope: In the human body there are reflexes in the nervous system that are not aware, this nerve reflex can cause a sudden drop in blood pressure. Vasovagal syncope as a result of the action of the vagus nerve which then sends signals to the heart and then slow the heart rate so someone fainting. Vasovagal syncope is usually triggered by fear, pain, injury, fatigue and prolonged standing. Other situations generally cause the heart rate to slow down and cause fainting while as straining, coughing, sneezing (Ocupational syncope) that can cause vagal response.
  • Carotid Sinus: Carotid Sinus is a part of the blood vessels of the neck are very sensitive to physical changes and strain the blood vessels in the area. Because it is too sensitive, then this will result in impulse transmission in the central nervous system that stimulates nerves that make losing consciousness.

3. Influence of body position
  • Orthostatic Hypotension.
  • Postural Hypotension: Blood vessels need to maintain their strength so that the body can withstand the effects of gravity with changes in position. When the body position change from lying to standing, autonomic nervous system increases the strength of the walls of blood vessels, making them shrink, and at the same time increasing the heart rate so that blood can be pumped went up to the brain that cause the blood pressure is relatively low at the moment stand. This is common in the elderly and pregnant women. Typically, fainting happens when a person stands with fast and there was not enough time for the body to compensate. This makes the heart beat faster, and occurs vasoconstriction of blood vessels to maintain the body's blood pressure and blood flow to the brain.

4. Lack of body components
  • Hypoglycemia: Decreased blood sugar suddenly causes a decrease in glucose available to brain function. This can be seen in diabetics who tend to overdose of insulin. If people miss a dose, the dose may be tempted to take extra insulin to make up the missed dose. In such cases, blood sugar tends to suddenly fall, and get people into insulin shock.
  • Electrolyte imbalance: This is due to changes in the concentration of fluid in the body and also directly affects blood pressure in the body.
  • Anemia: Anemia is a condition of a lack of red blood cells (erythrocytes), more specifically, is a hemoglobin (Hb). This causes a lack of oxygen reaching the brain that causes fainting, because hemoglobin is to transport oxygen to the cells in this case the cells in the brain.

5. Other causes
  • Pregnancy: It is caused by the pressure of the inferior vena cava (the large vein that returns blood to the heart) by the enlarged uterus and by orthostatic hypotension.
  • Medications: Other medications may also cause potentially of fainting or syncope including those for high blood pressure that can dilate blood vessels, antidepressants which can affect the heart's electrical activity, and that affects the mental state such as pain medications, alcohol, and cocaine.


Clinical Manifestations of Syncope

Signs symptoms of syncope can be seen in three phases which pre-syncope, syncope and post syncope.

1. Pre syncope:
Patients may feel nauseous, feeling uncomfortable, clammy and weak. There may be a feeling of dizziness or vertigo (the room spinning), hyperpnea (increased depth of breath), vision may be blurred, and there may dampen hearing and tingling sensations in the body. Pre-syncope or near-fainting, the same symptoms will occur, but at this stage the blood pressure and pulse down and the patient did not really lose consciousness.

2. Syncope:
Syncope is characterized by loss of consciousness of patients with clinical symptoms such as:
Short breathing, shallow and irregular.
Bradycardia and hypotension continues.
Palpable pulse weak and convulsive movement in arm muscles, legs and face. In this phase the patient vulnerable to airway obstruction due to the occurrence of muscle relaxation due to loss of consciousness.

3. Post syncope:
The last phase is the post syncope is a recovery period where patients return to consciousness. In the early phases of post-syncope patients may experience disorientation, nausea, and sweating. On clinical examination obtained palpable pulse began to rise and stronger and the blood pressure starts to rise.
After the episode of syncope, the patient should return to normal mental functioning, even though there may be signs and other symptoms depending on the underlying cause of syncope. For example, if the patient is in the midst of a heart attack, he may complain of chest pain or chest pressure.


Nursing Diagnosis and Interventions for Syncope

Nursing Diagnosis : Decreased cardiac output related to the disruption of blood flow to the heart muscle.

Goal: inadequate blood flow to the heart.

Expected outcomes: strong pulse palpation, normal blood pressure.

Intervention:
1. Check the ABC and if necessary freed airway and cardiac massage
Rational: Addressing critical condition early may improve the prognosis of clients.

2. Monitor the pulse rate, respiratory rate, BP regularly.
Rational: Vital signs as the reference condition the patient's circulation.

3. Check the state of the client's heart with ECG examination.
Rational: ECG examination provides an overview heart condition and help determine further treatment alternatives.

4. Assess changes in skin color towards cyanosis and pallor.
Rational: Pale showed a decrease in peripheral perfusion to inadequate cardiac output. Cyanosis occurs as a result of obstruction of blood flow to the ventricles.

5. Monitor intake and output every 24 hours.
Rationale: The kidneys respond to lower cardiac output with production hold fluid and sodium.

6. Limit activities adequately.
Rationale: Adequate rest is needed to improve the efficiency of cardiac contraction and lower oxygen consumption and excessive work.


Nursing Diagnosis : Ineffective Cerebral Tissue Perfusion related to a decrease in the flow of oxygen to the cerebral.

Expected outcomes: Vital signs are stable, patient-oriented with good communication.

Interventions:
1. Monitor vital signs
Rational: Vital Signs is one indicator of the general state and the patient's circulation.

2. Position the patient in the shock position foot raised 45 degrees.
Rationale: Helps improve venous return to the heart and subsequently increased cerebral blood flow.

3. Monitor the level of consciousness.
Rationale: The level of a person's consciousness is also influenced by the perfusion of oxygen to the brain.

4. Provide adequate oxygen therapy.
Rationale: to prevent more severe brain hypoxia.

3 Nursing Diagnosis and Interventions for Rheumatic Fever

 |  in Rheumatic Fever at  12:10 AM
Rheumatic fever is a multisystem collagen vascular disease that occurs after a group A streptococcal infection in individuals who have predisposing factors. This disease is still the most important cause of acquired heart disease in children and young adults in many countries, especially developing countries. The involvement of cardiovascular disease is characterized by inflammation of the endocardium and myocardium through an autoimmune process that causes tissue damage. The first attack of acute rheumatic fever occurs most often between the ages of 5-15 years. Rheumatic fever is rare in children under the age of 5 years.

Although knowledge and research has been growing rapidly, but the mechanism of occurrence of rheumatic fever is certainly unknown. In general, experts agree that rheumatic fever is included in autoimmune diseases.

The clinical course of rheumatic fever / rheumatic heart disease can be divided into :

Stage I

This stage in the form of upper respiratory tract infection by the bacteria Group A β-hemolytic streptococcus. Complaints typically include fever, cough, pain when swallowing, often accompanied by vomiting and even in young children diarrhea can occur. On physical examination often found in tonsillar exudate accompanying signs of inflammation. Submandibular lymph nodes are often enlarged. This infection usually lasts 2-4 days and can heal itself without treatment.
The researchers noted 50-90% history of upper respiratory tract infections in patients with rheumatic fever / rheumatic heart disease, which usually occurs 10-14 days before the first manifestations of rheumatic fever / rheumatic heart disease.

Stage II

This stage is also called the latent period, is the period between streptococcal infection, with the onset of the symptoms of rheumatic fever, this period usually lasts 1-3 weeks, unless chorea that may arise 6 weeks or even months later.

Stage III

Rheumatic fever is an acute phase, when the emergence of various clinical manifestations of rheumatic fever / rheumatic heart disease. The clinical manifestations can be classified in the general inflammatory symptoms (symptom minor) and specific manifestations (major symptoms) rheumatic fever / rheumatic heart disease.


3 Nursing Diagnosis and Interventions for Rheumatic Fever


1. Decreased cardiac output related to the disturbances on the closure of the mitral valve.

Goal: Decrease in cardiac output can be minimized.

Expected outcomes:
  • Vital signs within normal limits,
  • Normal ECG,
  • Free from symptoms of heart failure,
  • Adequate urine output of 0.5-2 ml / kg body weight,
  • Clients participate in activities that reduce the heart's workload.

Intervention:
  • Assess pulse, respiration, blood pressure regularly every 4 hours.
  • Note the heart sounds.
  • Assess changes in skin color towards cyanosis and pallor.
  • Monitor intake and output every 24 hours.
  • Limit activities adequately.
  • Give psychological condition quiet environment.


2. Ineffective Tissue perfusion related to a decrease in peripheral blood circulation.

Goal: adequate tissue perfusion.

Expected outcomes:
  • Vital sign within acceptable limits,
  • Intake and output balance,
  • Acral felt warm, cyanosis (-), peripheral pulse strong,
  • Patients conscious / oriented,
  • No edema,
  • Free of pain / discomfort.

Intervention
  • Monitor changes suddenly or continuous mental disorders (anxiety, confusion, lethargy, fainting).
  • Observation of pale, cyanosis, striped, skin cold / humid, record the strength of peripheral pulses.
  • Assess Homan's sign (pain in the calf with dorsiflexion), erythema, edema.
  • Encourage leg exercises active / passive.
  • Monitor breathing.
  • Assess GI function, record anorexia, decreased bowel sounds, nausea / vomiting, abdominal distension, constipation.
  • Monitor input and changes in urine output.


3. Activity intolerance related to the swelling and pain in the joints, muscle weakness, decreased cardiac output (imbalance between myocardial oxygen supply and needs).

Goal: The client can work within the limits of tolerance for that perfectly measured.

Expected outcomes:
  • Showed an increase in activity, the heart rate / rhythm and pressure within normal limits, warm skin, pink and dry.

Intervention
  • Assess the patient's tolerance for activity using the following parameters: pulse 20 beats / min above the resting pulse frequency, noted an increase in blood pressure, dyspnoea, chest pain, severe fatigue, weakness, sweating, dizziness or fainting.
  • Increase breaks, limit activity on the basis of pain / hemodynamic response, provide leisure activities that are not heavy.
  • Limit visitors or visits by patients.
  • Assess readiness to increase activities eg decrease weakness / fatigue, stable blood pressure / pulse rate, increased attention on the activities and self-care.
  • Suggest to promote activities / tolerance of self care.
  • Provide assistance as needed (eating, bathing, dressing, elimination).
  • Advise patients to avoid an increase in abdominal pressure, straining during defecation.
  • Describe the pattern of gradual increase of the activity, for example: sitting on the bed when no dizziness and no pain, getting up from the bed, learning to stand and so on.

Nursing Interventions for Risk for Injury related to Seizure

 |  in Risk for Injury at  9:02 PM
Nursing Care Plan for Epilepsy

Epilepsy is a symptom or manifestation of excessive loss of electrical charge in cells of the central nervous neurons that can cause loss of consciousness, involuntary movements, abnormal sensory phenomena, the increase in autonomic activity and a variety of physical disorders.

The impact on children, usually occurs as follows.
  1. Long Term General Effect, generally for long-term effects of the seizures are very dependent on the cause. Children who have epilepsy will have an impact on specific conditions, such as head injury and neurological disorders that have a higher mortality than the normal population.
  2. Effect on Memory and Learning. In general, children who experience seizures will be an impact pad expansion and brain disorders will occur ugliness. Children with uncontrolled seizures is a risk factor for the occurrence of intellectual decline.
  3. Social and Behavioral Consequences. Knowledge and language disorders, and emotional and behavioral disorders, occurs in a number of children with partial epilepsy syndromes. Children are usually dressed with a bad attitude compared to other children.

Manifestations of seizures can vary from mild to severe. Light as discomfort in the abdomen, and the weight can be a disturbance of consciousness, impaired motor function, sensory, autonomic, behavioral disorders. Actually, any person having a seizure origin can be made sufficiently strong stimulus is given, for example, electro-shock. When these stimuli exceeded the seizure threshold then the seizures.


Nursing Interventions for Risk for Injury related to Seizure

Goal: The client is not a seizure.

Expected outcomes:
  • Clients do not have seizures.
  • Children and families demonstrate an understanding of the possible responses to the drug that is not good and appropriate intervention.
  • Patients do not get injured.
  • Child and family approve or modify the activity of an appropriate activity for children.
  • Individuals associated with giving children appropriate interventions during and after the seizure.
  • Normal vital signs (blood pressure, pulse, respiration rate, temperature).

Interventions 

1. Encourage physical examination and laboratory periodically.
R /: Specifies possible deviations from normal findings.

2. Encourage good dental care during therapy.
R /: Lose the gum hyperplasia.

3. Encourage intake of vitamin D and folic acid adequate for therapy.
R /: Prevents deficiency.

4. Collaboration antilepsi in drug delivery.
R /: Provide appropriate therapy.

5. Stress the importance of complying with the therapeutic program.
R /: Provide appropriate therapy procedures.

6. Avoid situations that are known to trigger seizures, such as light flashes and fatigue.
R /: Preventing the occurrence of seizures.

7. Educate parents and children about appropriate activities for children (depending on the type, frequency, and severity of seizures).
R /: Provides information about the disease process.

8. Facilitate children during activities that are allowed, such as swimming, cycling.
R /: To prevent injury in the event of a seizure.

9. Instruct to shower with close supervision during bathing.
R /: To prevent injury in the event of a seizure.

10. Educate people closest to the client associated with the child about appropriate assistance during and after seizures.
R /: To prevent injury in the event of seizures and convulsions can deal quickly and appropriately.

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