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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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NCP - Nursing Assessment for Burns (Combustion)

Burns are a global public health problem. This is due to the high rate of burn mortality and morbidity, especially in low- and middle-income countries, where more than 95% of the incidence of burns causes death (mortality). However, death is not the only consequence of burns. Many burn patients eventually experience disability (morbidity). This often creates a stigma against community rejection. (Ziaeian, Boback and Gregg C. Fonarow. (2016).)

Burns (combustio) are tissue loss caused by contact with heat sources such as water, fire, chemicals, electricity, and radiation. Burns will cause not only skin damage, but also affect the entire body system (Brunner & Suddarth, 2014)

Burns are a form of tissue damage and or loss caused by contact with sources that have very high temperatures (eg fire, hot water, chemicals, electricity, and radiation) or very low temperatures. Upon contact with a heat source (or other cause). A chemical reaction takes place that drains energy from the tissue so that the cell is reduced and damaged (Moenadjat 2014)

Burns are damage to body tissues, especially the skin as a result of direct or intermediary with chemical, electrical, and radiation heat sources. Burns are wounds caused by heat trauma which give symptoms depending on the area and location of the wound (Brunner & Suddarth, 2014)

Nursing Assessment for Burns (Combustio)


Nursing Assessment

Assessment of patients with burns is intended to collect the latest data and information about the patient's status, with the assessment of the Iitegument system as an assessment priority. Systematic assessment of the patient includes a history specifically related to difficulty moving, palpitations. Each symptom should be evaluated for its time and duration as well as its precipitating factors.

1) Client identity. In addition to the client's name, age, gender, religion, occupation and education.

2) Activity/rest. Signs: decreased strength, resistance, limited range of motion in the affected area, impaired muscle mass, changes in tone.

3) Circulation. Signs: hypotension (shock), decreased peripheral pulse distal to the injured extremity, generalized peripheral vasoconstriction with loss of pulse, white and cold skin (electrical shock), tachycardia, dysrhythmias, tissue edema formation.

4) Ego integrity. Symptoms: problems with family, work, finances, disability. Signs: anxiety, crying, dependence, denial, withdrawal, anger.

5) Elimination. Signs: decreased/absent urine output during the emergency phase, color may be reddish black in the presence of myoglobin, indicating deep muscle damage, diuresis (after capillary leakage and mobilization of fluid into the body circulation), decreased bowel sounds are absent.

6) Food or liquid. Signs: generalized tissue oedema, anorexia, nausea/vomiting. Symptoms: decreased appetite, bowel sounds and decreased intestinal peristalsis, changes in bowel habits.

7) Neurosensory. Symptoms: border area, tingling. Signs: changes in orientation, affect, behavior, decreased deep tendon reflexes in extremity injuries, seizure activity, corneal laceration, retinal damage, decreased sharpness vision.

8) Pain/comfort. Symptoms: various pains, e.g., first degree burns are extremely sensitive to touch, pressure, air movement, and temperature changes.

9) Breathing. Symptoms: confined in an enclosed space, prolonged exposure (possible inhalation injury). Signs: shortness of breath, coughing wheezing, carbon particles in sputum, inability to swallow oral secretions and cyanosis, indications of inhalation injury. Thoracic expansion may be limited to the presence of burns to the chest circumference, airway or stridor/wheezing (obstruction related to laryngospasm, laryngeal edema), breath sounds: deep airway secretions (rhonchi).

10) Security. Signs: generalized skin: deep tissue instruction may not be evident for 3-5 days in connection with the process microvascular thrombus in some wounds.

11) Medical history

  • Chief complaint: infection in burns
  • History of present illness: Most or most of the causes of burns are due to electric shock, heat, temperature, chemical mediators.
  • Past medical history: the client does not have a history of previous illnesses related to burns.
  • Family history of disease: no case correlation on family members to the incidence of burn infection. (Price, A. Sylvia 2014)

Assessment, Nursing Diagnosis and Interventions for Pain

Assessment Techniques

Assessment and Nursing Diagnosis for Blepharitis

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6 Nursing Diagnosis for Empyema

 

6 Nursing Diagnosis for Empyema
Empyema

Empyema is defined as a collection of pus in the pleural cavity, gram-positive, or culture from the pleural fluid. Empyema is usually associated with pneumonia but may also develop after thoracic surgery or thoracic trauma. (www.ncbi.nlm.nih.gov)

Empyema is usually caused by an infection that spreads from the lung. It leads to a buildup of pus in the pleural space.

There can be 2 cups (1/2 liter) or more of infected fluid. This fluid puts pressure on the lungs.

Risk factors include: Bacterial pneumonia, Tuberculosis, Chest surgery, Lung abscess, Trauma or injury to the chest.

In rare cases, empyema can occur after thoracentesis. This is a procedure in which a needle is inserted through the chest wall to remove fluid in the pleural space for medical diagnosis or treatment. (medlineplus.gov)

Symptoms of empyema may include: having a case of pneumonia that does not improve, a fever, chest pain, a cough, pus in mucus, difficulty breathing, a crackling sound from the chest, decreased breathing sounds, dullness when tapping chest, fluid in the lungs (visible with a chest X-ray).

Empyema can progress through three stages if a person does not receive treatment. (www.medicalnewstoday.com)

Nursing Diagnosis for Empyema

  1. Ineffective breathing pattern related to shortness of breath, mucus, bronchoconstriction, fatigue.
  2. Ineffective airway clearance related to increased secretions, ineffective coughing.
  3. Activity intolerance related to reduced oxygen supply.
  4. Self-care deficit related to fatigue.
  5. Imbalanced nutrition: less than body requirements related to anorexia.
  6. Impaired gas exchange related to ventilation-perfusion imbalance.

 

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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

 

Stroke - Physical Examination (B1-B6) - Breathing, Blood, Brain, Bladder, Bowel and Bone

Stroke - Causes, Risk Factors, Symptoms and Problems that Occur After a Stroke

 

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NCP for Hallucinations - Assessment and Nursing Diagnosis

 

Hallucinations

Definition

Perception

Perception is the process of receiving stimuli until the stimuli are realized and understood by the senses or sensations: the process of receiving stimuli.

So perceptual disorders are human inability to distinguish between stimuli arising from internal sources such as thoughts, feelings, somatic sensations with external impulses and stimuli.


Hallucinations

Hallucinations are one of the perceptual disorders, where there is a sensory experience in the absence of sensory stimulation (false sensory perception). According to Cook and Fotaine (1987), hallucinations are sensory perceptions of an object, image and thought that often occur in the absence of external stimuli which can include all sensory systems (hearing, seeing, smelling, touching or tasting), while according to Wilson (1983) ), hallucinations are disturbances of absorption/perception of the five senses without any external stimulation that can occur in the sensory system which occurs when the individual's consciousness is good.


Causative Factors

According to Yosep (2009), the risk factors that cause hallucinations are divided into 2, namely:

1. Predisposing Factors

  • Development factor. Disrupted developmental tasks of clients, for example, low control and family warmth cause clients to be unable to be independent since childhood, easily frustrated, lose self-confidence and are more susceptible to stress.
  • Sociocultural factors. A person who feels unaccepted by the environment since he was an infant (unwanted child) will feel excluded, lonely, and distrustful of his environment.
  • Biochemical factors. Biochemical factors have an influence on the occurrence of mental disorders. The presence of excessive stress experienced by a person then in the body will produce a substance that can be neurochemical hallucinogenic such as Buffofenon and Dimetytransferase (DMP). Due to prolonged stress causes activation of brain neurotransmitters. For example, there is an imbalance of acetylcholine and dopamine.
  • Psychological factors. Weak and irresponsible personality types easily fall into addictive substance abuse. This affects the client's inability to make the right decisions for his future. Clients prefer momentary pleasures and flee from the real world to the imaginary realm.
  • Genetic factors and parenting. Research shows that healthy children raised by schizophrenic parents are more likely to develop schizophrenia. The results of the study show that family factors show a very influential relationship in this disease.

 

2. Precipitation Factor
The client's response to hallucinations can be in the form of suspicion, fear, feelings of insecurity, anxiety, and confusion, self-destructive behavior, lack of attention, inability to make decisions and unable to distinguish real and unreal situations.
According to Rawlins and Heacock (in Yosep, 2009) trying to solve the problem of hallucinations based on the nature of the existence of an individual as a creature that is built on the basis of bio-psycho-socio-spiritual elements so that hallucinations can be seen from five dimensions, namely:

  1. Physical Dimension. Hallucinations can be caused by several physical conditions such as extreme fatigue, drug use, fever to delirium, alcohol intoxication and difficulty sleeping for a long time.
  2. Emotional Dimension. Excessive feelings of anxiety on the basis of insurmountable problems are the cause of the hallucinations. The content of hallucinations can be coercive and frightening commands. The client is no longer able to oppose the order until the client does something about this fear.
  3. Intellectual dimension. In the intellectual dimension, it is explained that individuals with hallucinations will show a decrease in ego function. At first hallucinations are an attempt by the ego itself to fight the pressing impulses, but it is something that causes alertness that can take all the attention of the client and often will control all the behavior of the client.
  4. Social dimension. The client experiences social interaction disorders in the early and comfortable phase, the client considers that social life in the real world is very dangerous. The client is engrossed in his hallucinations, as if he were a place to fulfill needs for social interaction, self-control and self-esteem that are not found in the real world. The content of the hallucinations is used as a control system by the individual, so that if the hallucinations command a threat, he or other individuals tend to do so.
  5. The spiritual dimension. Spiritually, client hallucinations begin with the emptiness of life, meaningless routines, loss of worship activities and rarely spiritual efforts to purify themselves. His circadian rhythm is disturbed, because he often sleeps late at night and wakes up very late. When he wakes up feeling empty and not clear about his purpose in life. He often curses fate but is weak in trying to pick up fortune, blaming the environment and other people for causing his destiny to worsen.


 

Assessment

In the assessment process, important data that needs to be studied are adjusted to the type of hallucination, namely, as follows:

1. Types of hallucinations

a. Auditory Hallucinations

  • Objective Data: Talking or laughing alone, getting angry for no reason, tilting the ear in a certain direction, covering the ears.
  • Subjective Data: Hearing voices or noise, hearing voices that invite conversation, hearing voices telling to do something dangerous.

b. Visual Hallucinations

  • Objective Data: Pointing in a certain direction, fear of something that is not clear.
  • Subjective Data: Seeing shadows, rays, cartoon shapes, seeing ghosts or monsters.

c. Smell Hallucinations

  • Objective Data : Smells like certain odors, covers the nose.
  • Subjective Data: Smelling odors such as the smell of blood, urine, feces, sometimes the smell is pleasant.

d. Taste Hallucinations

  • Objective Data: Frequent spitting, vomiting.
  • Subjective Data : Feel the taste like blood, urine or faeces.

e. Touching Hallucinations

  • Objective Data : Scratching the skin surface.
  • Subjective Data : Says there are insects on the skin surface, feels like being electrocuted.



Nursing Diagnosis :

  1. Disturbed Sensory Perception : Auditory Hallucinations
  2. Risk for violence
  3. Ineffective Therapeutic Regimen Management
  4. Post Traumatic Stress Disorder
  5. Social isolation
  6. Low self-esteem
  7. Disturbed Thought Processes

 

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