4 Nursing Diagnosis and Interventions for Tetanus

Nursing Diagnosis and Interventions for Tetanus

1. Ineffective Airway Clearance related to the accumulation of sputum in the trachea and respiratory muscle spam

Characterized by rhonchi, cyanosis, dyspnea, ineffective cough accompanied by sputum and/or mucus.

Goal: Effective airway

Outcomes :

• No shortness of breath, no mucus or sleam.
• Normal breathing.
• No nostril breathing.
• No additional respiratory muscles.

Intervention and Rationale:

1. Free the airway by adjusting the head extension position.

R / : Anatomically, the extension head position is a way to straighten the respiratory cavity so that the respiratory process remains effective by eliminating airway obstruction.

2. Physical examination by auscultation listening to breath sounds every 2-4 hours.

R / : Ronchi indicates a respiratory disorder due to fluid or secretions that cover part of the respiratory tract, so it needs to be removed to optimize the airway.

3. Clean the mouth and airways of secretions and mucus by suction.

R / : Suction is an action to help remove secretions, thus facilitating the process of respiration.

4. Collaboration of oxygenation.

R/: Adequate oxygen supply can supply and provide oxygen reserves, thereby preventing hypoxia.

5. Observation of vital signs every 2 hours.

R / : Dyspnea, cyanosis is a sign of respiratory problems, accompanied by decreased cardiac work, tachycardia and capillary refill time are prolonged.

6. Observe the onset of respiratory failure.

R / : The body's inability to process respiration requires a critical intervention using a breathing apparatus (mechanical ventilation).

7. Collaboration in the administration of secretion-thinning drugs (mucolytics).

R / : Mucolytic drugs can thin thick secretions, making it easier to excrete and prevent viscosity.

2. Ineffective Breathing Pattern related to disturbed airway due to spasm of the respiratory muscles

Characterized by excitatory spasms, contraction of the respiratory muscles, and accumulation of mucus and secretions.

Goal: Regular and normal breathing pattern

Outcomes :

• Hypoxaemia is resolved, there is an improvement in the fulfillment of oxygen needs.
• No shortness of breath, normal breathing.
• No cyanosis

Interventional and Rational :

1. Monitor respiratory rhythm and respiratory rate.

R / : Indications of irregularities or abnormalities of breathing can be seen from the frequency, type of breathing, ability and rhythm of breathing.

2. Adjust the position to straighten the airway.

R / : The airway is loose and there is no obstruction of the respiratory process

3. Observe for signs and symptoms of cyanosis.

R / : Cyanosis is a sign of inadequate supply of oxygenation to peripheral body tissues.

4. Collaboration of oxygen delivery

R/: Adequate oxygen supply can supply and provide oxygen reserves, thereby preventing hypoxia.

5. Observation of vital signs every 2 hours.

R / : Dyspnea, cyanosis is a sign of respiratory disorders accompanied by decreased heart work, tachycardia and capillary refill time are prolonged.

6. Observe the onset of respiratory failure.

R / : The inability of the body in the process of respiration requires a critical intervention using a breathing apparatus (mechanical ventilation).

7. Collaboration in the examination of blood gas analysis.

R / : The body's compensation for disruption of the process of diffusion and tissue perfusion.

3. Imbalanced Body Temperature (hyperthermia) related to toxin effect (bacteremia)

Characterized by body temperature 38-40 oC, hyperhydration, white blood cells more than 10,000 / mm3.

Goal: Normal body temperature

Outcomes :

• Normal body temperature (36-37oC)
• The laboratory results of white blood cells (leukocytes) are between 5,000-10,000/mm3.

Intervention and Rationale:

1. Set a comfortable ambient temperature.

R/ : Environmental climate can affect the condition and individual body temperature as an adaptation process through evaporation and convection processes.

 2. Monitor body temperature every 2 hours.

R / : Identify the development of symptoms towards shock exhaution.

3 . Provide adequate hydration or drink.

R / : Fluid helps to refresh the body and is a compression of the body from within.

4. Perform aseptic and antiseptic techniques in wound care.

R / : Wound treatment eliminates the possibility of toxins that are still around the wound.

5. Implement a program of antibiotic and antipyretic treatment.

R / : Antibacterial drugs can have a broad spectrum to treat gram positive bacteria or gram negative bacteria. Antipyretics work as a thermoregulatory process to anticipate heat.

7. Collaborative in leukocyte laboratory examination.

R / : The results of the examination of leukocytes that increase more than 10,000 / mm3 indicate an infection and or to follow the progress of the treatment programmed.

4. Imbalanced Nutrition: Less Than Body Requirements related to chewing muscle stiffness

Characterized by insufficient intake, food and drinks that enter through the mouth can return again through the nose and decreased body weight accompanied by the results of the examination of protein or albumin less than 3.5 mg%.

Goal: Nutritional needs are met.

Outcomes :

• Optimal weight
• Adequate intake
• Albumin examination results 3.5-5 mg %

Intervention and Rationale:

1. Explain the factors that affect difficulty in eating and the importance of food for the body.

R / : The impact of tetanus is the stiffness of the masticatory muscles so that the client has difficulty swallowing and sometimes reflex back or choking occurs. With an adequate level of knowledge, clients are expected to be participative and cooperative in the diet program.

2. Collaborative:

a. The provision of a high-calorie and high-protein diet is liquid, soft or coarse porridge.

R / : Diet given in accordance with the client's state of the level of opening the mouth and chewing process.

b. Administration of intravenous fluids

R / : Giving intravenous fluids given to clients with the inability to chew or can not eat by mouth so that nutritional needs are met.

c. NGT installation if necessary

R / : NGT can serve as the entry of food as well as to give medicine.

Reference:

Brunner & Suddarth. 2002.

Doengoes, ME .2000

Lynda Juall C, 2003.

Smeltzer, Suzane C. 2002.

Physical Examination for Clients with Nervous System Disorders - Tetanus 

Source : https://nandacareplan.blogspot.com/2021/06/4-nursing-diagnosis-and-interventions.html

Risk for Injury - Nursing Diagnosis and Interventions for Glaucoma

 Nursing Diagnosis and Interventions for Glaucoma

Risk for Injury

Glaucoma is a group of eye diseases which result in damage to the optic nerve (or retina) and cause vision loss. The most common type is open-angle (wide angle, chronic simple) glaucoma, in which the drainage angle for fluid within the eye remains open, with less common types including closed-angle (narrow angle, acute congestive) glaucoma and normal-tension glaucoma. Open-angle glaucoma develops slowly over time and there is no pain. Peripheral vision may begin to decrease, followed by central vision, resulting in blindness if not treated. Closed-angle glaucoma can present gradually or suddenly. The sudden presentation may involve severe eye pain, blurred vision, mid-dilated pupil, redness of the eye, and nausea. Vision loss from glaucoma, once it has occurred, is permanent. Eyes affected by glaucoma are referred to as being glaucomatous.

Nursing Diagnosis :

Risk for Injury related to decreased visual field

Risk Factors:

External

• Physical (example: design of community structures and codes, buildings and or equipment; mode of transport or mode of movement; people or service providers)
• Biological (pattern: level of immunization in the community, microorganisms)
• Chemicals (drugs: pharmaceutical agents, alsohol, caffeine, nicotine, preservatives, cosmetics; nutrients: vitamins, types of food; toxins; pollutants)

Internal

• Psychologic (affective orientation)
• Malnutrition
• Abnormal blood form, pattern: leukocytosis/leukopenia
• Changes in clotting factors
• Thrombocytopenia
• Sickle cell
• thalassemia,
• decrease in Hb,
• Immune doesn't work.
• Biochemistry, regulatory functions (e.g. sensory dysfunction)
• Dough dysfunction
• Effector dysfunction
• Tissue hypoxia
• Age development (physiological, psychosocial)
• Physical (example: skin damage/not intact, related to mobility)

Nursing Interventions :

Goals / Outcome Criteria: 

NOC :

Risk Control

Immune status
Safety Behavior
After nursing actions for…. The client does not experience injury with the following criteria:

• Client free from injury
• Clients can explain ways/methods to prevent injury/injury
• The client can explain risk factors from the environment / personal behavior
• Able to modify lifestyle to prevent injury
• Using existing health accommodation
• Able to recognize changes in health status

NICs :

Environment Management

• Provide a conducive environment for the patient
• Identify the patient's safety needs, according to the patient's physical condition and cognitive function and the patient's previous medical history
• Avoiding hazardous environments (e.g. moving furniture)
• Installing the bed side rail
• Provide a comfortable and clean bed
• Place the light switch in a place that is easily accessible to the patient.
• Restrict visitors
• Provide sufficient explanation
• Encourage the family to accompany the patient.
• Control the environment from noise
• Move items that can be dangerous
• Provide clarification to the patient and family or visitors of any changes in health status and causes of illness.

Source : https://nandacareplan.blogspot.com/2021/08/risk-for-injury-nursing-diagnosis-and.html

Nursing Intervention for Patients with Low Self-Esteem

 

Low self esteem is feeling worthless, meaningless, and low self-esteem due to a negative evaluation of self and self-efficacy. Lost their sense of self-confidence, sense of failure for not being able to achieve the ideal fit themselves desire.

Nursing intervention for patients

Goal:
Conduct an assessment of things behind the low self-esteem on the client (predisposing factor, precipitation factor, an assessment of the stressor, coping resources and coping mechanisms)
The client can raise awareness about the positive relationship between self-esteem and effective problem solving.
The client can identify, on its positive capabilities.

Nursing Interventions:

1. Assess the things behind the low self-esteem on the client (predisposing factor, precipitation factor, an assessment of the stressor, coping resources and coping mechanisms)

2. Raise awareness about the positive relationship between self-esteem and effective problem solving, by the way:
Help the patient to identify changes in sense of self.
Help the patient in describing clearly the situation in a positive self-evaluation earlier.
Exploration with the patient, neighborhood, organization, job (stability of the organization, interpersonal conflict, a threat to the current job)
Involve the patient in problem solving (identify objectives to increase and develop an action plan to meet the goals).

3. Provide support for self-care skills for self-esteem, by the way:
Together with the patient to identify the positive aspects that are still owned by the client
Train the client to optimize the positive aspects that still has
Enter into the schedule, the activities that can be done to optimize its positive aspects


Nursing intervention for patients' families

Patient's family is expected to care for patients with low self-esteem at home and become an effective support system for the patient.

Goal:
Patient's family help patients identify the ability of the patient
Patient's family to facilitate the implementation of the capabilities that are still owned by the patient
Patient's family motivate patients to engage in activities that are already trained and give credit for the success of the patient
Patient's family is able to assess developmental changes in patients' ability

Nursing Intervention:
1. Discuss the problems faced by families in caring for the patient
2. Explain to the family of low self-esteem who exist in a patient
3. Discussion with the patient's family capabilities and praise
     patients on their ability
4. Describe ways to care for patients with low self-esteem
5. Demonstrate how to treat a patient with low self-esteem
6. Give the opportunity for families to practice how to care for patients with low self-esteem
7. Assist family in preparing the action plan patients at home 

 

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Nursing Diagnosis and Interventions for Non Hemorrhagic Stroke

 

Nursing Diagnosis for Non Hemorrhagic Stroke :

1. Ineffective Tissue Perfusion :  cerebral related to decreased brain oxygen
2. Imbalanced Nutrition: Less Than Body Requirements related to inability to absorb nutrients
3. Impaired Physical Mobility related to decrease muscle strength
4. Risk for Impaired Skin Integrity related to risk factor : damp
5. Impaired Verbal Communication related to neuromuscular damage, speech central damage
   

 

Nursing Interventions for Non Hemorrhagic Stroke

No.	Nursing Diagnosis	Goal (NOC)	Interventions (NIC)	Rationale
1.	Ineffective Tissue Perfusion :  cerebral related to decreased brain oxygen	Tissue perfusion can be achieved optimally   Expected Outcome : ·      Able to maintain level of consciousness ·      Sensory and motor function getting better	1.   Monitor vital signs hourly and record the result 2.   Assess motor response to simple commands 3.   Monitor neurological status regularly 4.   Encourage active/passive leg exercises 5.   Collaboration: drug delivery according to indication	1.      An increase in systemic blood pressure followed by a decrease in diastolic blood pressure is a sign of increased ICP. 2.      Irregular breathing indicates an increase in ICP 3.      Able to determine the level of motor response of the patient 4.      Prevent/reduce atelectasis 5.      Reduces venous static 6.      Reduce the risk of complications
2.	Imbalanced Nutrition: Less Than Body Requirements related to inability to absorb nutrients	1.   Nutritional status 2.   Food intake 3.   Fluids and nutrients   Expected Outcomes : ·     Explain the components of diet closeness ·     Report adequacy nutritional level ·     Laboratory values ​​(eg: transferrin, albumen and electrolyte ·     Tolerance to good nutrition recommended.	1.    Disturbance management food 2.    Nutrition management 3.    Help to gain weight   Nursing activities: 1.    Determine the client's motivation to change eating habits 2.    Know the client's favorite food 3.    Refer to a doctor to determine the cause of nutritional changes 4.    Help eat according to client's needs 5.    Create an environment that fun to eat	1.    The client's motivation influences the change in nutrition 2.    The client's favorite food to facilitate the provision of nutrition 3.    Refer to the doctor to find out the changes in the client and for the healing process 4.    Help eat to know nutritional changes 5.    Creating an environment for the comfort of the client's rest as well as for tranquility in the room.
3.	Impaired Physical Mobility related to decrease muscle strength	Show increased mobility, indicated by the following indicators (state the value 1 – 5) : dependent (not participating) requires the help of others or the tool requires the help of others, independent with the help of assistive devices or fully independent).   Expected Outcomes : ·     Demonstrate the correct use of assistive devices with supervision. ·     Asking for assistance in mobilizing activities if needed. ·     Use a wheelchair effectively.	1.    Activity therapy, ambulation 2.    Activity therapy, joint mobility. 3.    Position change   Nursing activities: 1.    Teach clients about the use of tools 2.    Assist mobility. 3.    Teach and assist clients in the transfer process. 4.    Provide positive reinforcement during activities. 5.    Support ROM training techniques 6.    Collaboration with the medical team on client mobility	1.         Teach clients about and monitor the use of mobility aids clients more easily. 2.         Helping clients in the transfer process will help clients practice in this way. 3.         Giving positive reinforcement during the activity will help the client to be enthusiastic in training. 4.         Accelerate the client in mobilization and relax the muscles 5.         Knowing the client's mobilization development after ROM exercises 6.         Collaboration with the medical team can help improve patient mobility such as collaboration with doctors
4.	Risk for Impaired Skin Integrity related to risk factor : damp	Tissue Integrity : Skin and Mucous Membranes   Expected Outcomes : ·     Good skin integrity can be maintained (sensation, elasticity, temperature, hydration, pigmentation) ·     There are no wounds / lesions on the skin ·     Demonstrate understanding in the skin repair process and prevent repeated injury ·     Able to protect the skin and maintain skin moisture and natural care	1.    Advise the patient to wear loose clothing 2.    Avoid wrinkles on the bed 3.    Keep the skin clean to keep it clean and dry 4.    Patient mobilization (change patient position) every two hours 5.    Monitor the skin for redness 6.    Apply lotion or oil/baby oil on stressed areas 7.    Collaboration giving antibiotics as indicated	1.    Skin may be damp and may feel unable to rest or need to move 2.    Reduce the risk of infection on the skin 3.    The first way to prevent infection 4.    Prevent further complications 5.    Knowing the development of the occurrence of skin infections 6.    Reduce exposure to infectious germs on the skin 7.    Reduce the risk of infection
5.	Impaired Verbal Communication related to neuromuscular damage, speech central damage	Good communication   Expected Outcomes : ·     Clients can express feelings ·     Understanding the intentions and conversations of others ·     The patient's speech can be understood	1.   Communicate with reasonable, clear, simple language and if necessary repeated 2.   Listen carefully when the patient starts talking 3.   Stand in the patient's field of view when speaking 4.   Exercise your speech muscles optimally 5.   Involve the family in practicing verbal communication with the patient 6.   Collaboration with speech therapists	1.    Checking the client's communication whether it really can't do communication 2.    Knowing how the client's communication skills 3.    Knowing the degree / level of communication skills 4.    Reduce the occurrence of further complications 5.    Families know & are able to demonstrate how to practice verbal communication to clients without the help of nurses 6.    Knowing the development of the client's verbal communication

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