Disturbed Body Image related to Rheumatoid Arthritis

 Nursing Care Plan for Rheumatoid Arthritis

Rheumatoid arthritis is a disease which has long been known and spread throughout the world and involving all races and ethnic groups. Rheumatoid arthritis is often found in women, with the ratio of women to men is 3: 1. The tendency for women suffering from rheumatoid arthritis and remissions are common in women who are pregnant, this raises the suspicion of the presence of hormonal balance factor as one of the factors that affect this disease.

Most patients show symptoms of chronic intermittent disease, which if left untreated will cause damage to joints and progressive joint deformity that causes disability and even premature death.

Disturbed Body Image related to changes in the ability to perform the duties of a general, an increase in energy use, the imbalance of mobility.

Evidenced by:

• Changes in the function of diseased body parts.
• Focus on past strength and appearance.
• Changes in lifestyle / physical ability to continue the role, job loss, dependence on the nearest person.
• Changes in social engagement; a feeling of isolation. Feelings of helplessness, hopelessness.

Expected outcomes: The patient will :

• Expressing increased confidence in the ability to cope with illness, changes in lifestyle, and possible limitations.
• Develop a realistic plan for the future.

Intervention and Rationale

1. Encourage disclosure about the problem of the disease process, hope for the future.
R /: Give the opportunity to identify the fear / misconceptions and deal with it directly.

2. Discuss the meaning of loss / change in patients / people nearby. Ascertain how the patient's personal views on the functioning of day-to-day lifestyle.
R /: Identify how the disease affects self-perception and interaction with others will determine the need for intervention / counseling further.

3. Discuss the patient's perception of how the people closest to accept limitations.
R /: Gestures verbal / non-verbal people nearby can have a major influence on how the patient sees himself.

4. Acknowledge and accept the feelings of the bereaved, hostile, dependency.
R /: constant pain would be exhausting, and feelings of anger and hostility are common.

5. Pay attention to the behavior of withdrawing, denying use or too noticed a change.
R /: Can demonstrate emotional or maladaptive coping methods, requiring further intervention.

7. Involve patients in the treatment plan and schedule of activities.
R /: Increase the feeling of self-esteem, encourage independence, and encourage participation in therapy.

8. Assist in need of care required.
R /: Maintaining the appearance that can improve self-image.

9. Provide positive support when necessary.
R /: Allows patients to feel good about themselves. Reinforcing positive behavior. Increase confidence.

10. Collaboration: Refer to psychiatric counseling, eg specialist psychiatric nurse, psychologist.
R /: Patient / person nearby may need support for dealing with long-term process / incapacity.

11. Collaboration: Give medicines as directed, eg; antianxiety drugs and mood enhancer.
R /: It may be required at the time of the advent of the Great Depression, until the patient increases coping abilities more effectively.

Nursing Diagnosis for Rheumatoid Arthritis

 

Source : Disturbed Body Image related to Rheumatoid Arthritis - Nursing Care Plan (free-nursingcareplan.blogspot.com)

Nursing Care Plan for Nausea and Vomiting

Nausea

Nausea is a sensation of unease and discomfort in the upper stomach with an involuntary urge to vomit. It often, but not always, preceded vomiting. A person can suffer nausea without vomiting. Some common causes of nausea are motion sickness, gastroenteritis (stomach infection) or food poisoning, side effects of many medications including cancer chemotherapy, or morning sickness in early pregnancy. Medications taken to prevent nausea are called antiemetics and include diphenhydramine, metoclopramide and ondansetron. Nausea may also be caused by stress and depression.


Vomiting

Vomiting (known medically as emesis and informally as throwing up and a number of other terms) is the forceful expulsion of the contents of one's stomach through the mouth and sometimes the nose. Vomiting may result from many causes, ranging from gastritis or poisoning to brain tumors, or elevated intracranial pressure. The feeling that one is about to vomit is called nausea, which usually precedes, but does not always lead to, vomiting. Antiemetics are sometimes necessary to suppress nausea and vomiting, and, in severe cases where dehydration develops, intravenous fluid may need to be administered to replace fluid volume.

Vomiting is different from regurgitation, although the two terms are often used interchangeably. Regurgitation is the return of undigested food back up the esophagus to the mouth, without the force and displeasure associated with vomiting. The causes of vomiting and regurgitation are generally different.
en.wikipedia

How is nausea or vomiting treated?

Symptomatic treatment may occur while the underlying illness is being investigated because ideally, nausea and vomiting should resolve when the cause of the symptoms resolves.

Nausea and vomiting are often made worse when the patient is dehydrated, resulting in a vicious cycle. The nausea makes it difficult to drink fluid, making the dehydration worse, which then increases the nausea. Intravenous fluids may be provided to correct this issue.

There are a variety of anti-nausea medications (antiemetics) that may be prescribed. They can be administered in different ways depending upon the patient's ability to take them. Medications are available by pill, liquid, or tablets that dissolve on or under the tongue, by intravenous or intramuscular injection, or by rectal suppository.

Common medications used to control nausea and vomiting include promethazine (Phenergan), prochlorperazine (Compazine), droperidol (Inapsine) metoclopramide (Reglan), and ondansetron (Zofran). The decision as to which medication to use will depend on the specific situation.
www.medicinenet.com

Nursing Diagnosis and Intervention Nursing Care Plan for Nausea and Vomiting

Nursing Diagnosis: Fluid and electrolyte deficit related to excessive fluid output.

Purpose: devisit fluid and electrolyte resolved

Expected outcomes: The signs of dehydration do not exist, the mucosa of the mouth and lips moist, fluid balance.

Nursing Intervention:

• Observation of vital signs.
• Observation for signs of dehydration.
• Measure infut and output of fluid (fluid balance).
• Provide and encourage families to provide drinking a lot of approximately 2000 - 2500 cc per day.
• Collaboration with physicians in the provision of therafi fluid, electrolyte laboratory tests.
• Collaboration with a team of nutrition in low-sodium fluids.

Nursing Diagnosis: Risk for Fluid Volume Deficit related to a sense of nausea and vomiting

Purpose: Maintaining the balance of fluid volume.

Expected outcomes: The client does not nausea and vomiting.

Nursing Intervention:

• Monitor vital signs.
• Rational: This is an early indicator of hypovolemia.
• Monitor intake and urine output and concentration.
• Rationale: Decreased urine output and concentration will improve the sensitivity / sediment as one suggestive of dehydration and require increased fluids.
• Give fluid little by little but often.
• Rationale: To minimize loss of fluid.
• The risk of infection associated with an inadequate defense of the body, characterized by: body temperature above normal. Respiratory frequency increased.

Source : Nursing Care Plan for Nausea and Vomiting - Nursing Care Plan (free-nursingcareplan.blogspot.com)

Nursing Care Plan for Anorexia Nervosa and Bulimia Nervosa

 Anorexia Nervosa and Bulimia Nervosa

Anorexia Nervosa

Definition

Anorexia Nervosa is a psychological disease in the form of deliberate starvation due to body image disturbances, excessive fear and irrational about weight gain. (Kimberly, 2011)

Anorexia Nervosa is a food disorder characterized by voluntary hunger and stress from doing exercises that involve psychological, sociological, physiological. (Arif Muttaqin, 2010)

According to the National Eating Disorders Association (NEDA, 2012), anorexia nervosa is a serious and potentially life-threatening disease in which eating disorders are characterized by hunger and excessive weight loss.


Etiology

The exact cause of anorexia nervosa is not known with certainty, but there are several factors as follows;

1. Biological Factors
   
   • Hunger or starvation will cause changes in neuropeptide activity and contribute to neuroendocrine disorders in anorexia nervosa patients.
   • There is a research on the function of the hypothalamic-pituitary-adrenal (HPA) axis in patients with anorexia nervosa in principle found hypercortisolism in which HPA plays a role in releasing the hormone corticotropin which affects patients to anorexia. (Licino, 1996)
   • The central pathway of serotonin eating regulates eating patterns and also participates in regulation of behavior and mood. Disorders of regulatory regulation and mood. Impaired regulation of serotonin regulation has implications for general depressive conditions that clearly will cause eating disorders. In the study of impaired serotonin regulation there is an increased risk of anorexia nervosa. (Jimerson, 1990)
   • Determination of ghrelin, glucose-dependent insulinotropic polypeptide (GIP) provides an increased response to anorexia. A decrease in GIP occurs in objects, although a small intake of calories prevents rapid insulin response in patients with anorexia. (Stock, 2005)
   • In conditions of depressed thyroid function, this abnormality can only be corrected by elimination. Hunger also causes amenorrhea that shows hormone levels (Luitenizing Hormone FSH, Gonadotropin, Realisine Hormone). Even so, some patients with anorexia nervosa suffer from amenorrhea before significant weight loss.
2. Sociocultural factors, anorexia nervosa patients have a family history of depression, alcohol dependence or eating disorders.
   
3. Psychological factors, fear of being fat, pressure to excel, social behavior that equates leanness with beauty.

Pathophysiology

In chronic conditions it provides a decrease in essential fatty acid content (Holman, 1995) which provides manifestations of decreased prostagladin synthesis as a constituent and protective mucous membrane which causes the patient to have a high risk of mucous membrane injury. Lack of fat intake and activities that are always carried out with the aim of losing weight so that patients tend to be weak and provide manifestations of disruption of daily activities, as well as the risk of secondary infection from decreased immunity.

The condition of chronic anorexia nervosa also has an impact on increasing the risk of osteoporosis as a result of shrinkage of bone mass or bone mineral density decreases thus providing a risk of pathological fracture. (Ringgoti, 1995)

Decreased calorie intake reduces fat reserves to be synthesized and protein in the body, endocrine disruption involving the hypothalamic-pituitary-gonadal axis occurs, resulting in estrogen deficiency which causes amenorrea. Whereas in men fluctuating testosterone levels that cause decreased erectile function and sperm count. (Kimberly, 2011)

In addition, a lack of calorie intake will have an impact on decreasing gastrointestinal motility, causing slowing of gastric emptying and constipation. (Wals, 2008)

The most serious risk of anorexia is the deterioration of intolerable physical conditions which increases the risk of death in some anorexia nervosa individuals.


Clinical Manifestations

According to the National Eating Disorders Association (NEDA, 2012), anorexia nervosa has four main symptoms as follows;

1. Resistance maintains weight at or above the minimum body weight that is normal for age and height.
2. Fear of being fat, even though body weight is below normal.
3. Dissatisfaction with certain aspects of physical appearance or serious self-rejection of low body weight.
4. Loss of menstrual periods in girls and post-puberty women.

Anorexia nervosa patients can be treated well on an outpatient basis. However, if the patient shows any of the following signs, the patient must be hospitalized;

1. Rapid weight loss is equivalent to 15% or more of normal body mass.
2. Persistent bradycardia (50 times / minute or less)
3. Systolic hypotension is less than or equal to 90 mmHg
4. Hypothermia (core body temperature less than or equal to 36.1ºC)
5. Medical complications found, suicidal thoughts
6. Persistent sabotage or obstacles to outpatient therapy due to rejection of the condition and the need for therapy

Bulimia Nervosa

Definition

Bulimia nervosa is a behavioral disorder characterized by fond of eating followed by guilt, contempt and self-deprecation where vomiting is induced alone, use of laxatives or diuretics, or restricting diet or fasting to overcome the effects of overeating. (Kimberly, 2011)

Bulimia nervosa is a recurring episode of binge eating and then with compensatory treatment (vomiting, fasting, serving, or a combination thereof). Overeating is accompanied by the subjective feeling of losing control when eating. Vomiting that is intentional or exaggerated, and abuse of laxatives, diuretics, amphetamines and thyroxine can also occur. (Chavez and Insel, 2007).

According to the National Eating Disorders Association (NEDA), bulimia nervosa is an eating disorder characterized by excessive eating cycles and compensatory behaviors such as self-induced (vomiting) are designed to cancel or compensate for the effects of large meals outside normal eating portions.


Etiology

The cause of bulimia nervosa can not be known with certainty, but there are factors as follows;

1. Biological factors, mental disorders are also caused by chemical processes in the brain, namely the presence of neurotransmitter abnormalities in the brain, primarily the neurotransmitter serotonin is a trigger for bulimia nervosa.
2. Psychological factors, appearance problems, lack of confidence in the weight they have, family conflicts.
3. Cultural factors, excessive emphasis on physical appearance due to cultural influences.

Pathophysiology

Decreasing calorie intake will reduce fat and protein stores in the body. Estrogen deficiency occurs in women due to lack of pleated substrates for synthesis, causing amenorrea. Whereas in men, there is also a decrease in erectile function and sperm count as a result of fluctuating testosterone levels. (Kimberly, 2011)

Caused by repeated vomiting, a person suffering from bulimia nervosa will experience an electrolyte imbalance and nutrients are not fulfilled properly (malnutrition). Vomiting also causes erosion of tooth enamel, especially the surface of the tongue, the back of the tongue (because it is often affected by finger friction to induce vomiting).

 Unlike anorexia nervosa, bumilia nervosa does not interfere with bone mineral density, this can occur depending on age, body weight (the thinner the more at risk). Most patients with bulimia nervosa experience depression which results in suicide attempts.


Clinical Manifestations

According to the National Eating Disorders Association (NEDA, 2012) bulimia nervosa has three main symptoms as follows;

1. Regular intake of large amounts of food is accompanied by a sense of loss of control when eating.
2. Usually use inappropriate self-induced compensation behaviors such as vomiting, laxative or diuretic abuse, fasting, or exercise.
3. Extreme attention to body weight and body shape.

Nursing Care Plan

Assessment


The identity examined includes name, age, gender, place of residence as a description of environmental and family conditions, and other information about the patient's identity.

1. Psychological and lifestyle assessments are usually found in adolescents and consider themselves unattractive, unhealthy and undesirable.
2. Psychosocococcal assessment and environmental conditions in the family.

The main complaint, the desire to be thin because they feel overweight.

1. Previous medical history, often obtained by the use of appetite suppressant drugs, diuretics, laxatives (laxatives) or alchohol.
2. Family health history, assesses whether or not a family has experienced bulimia or anorexia nervosa.
3. Physical examination.Physical examination is carried out to assess any changes or disturbances to the vital function of anthropometry: Body weight and anthropometric examination is carried out to assess nutritional status. Widespread endocrine disruption involves the hypotalamus pituytary-gonadal axis, with manifestations in women as amenorrhoea and in men ie loss of interest and seyual potential.
4. Supporting investigation
5. Laboratory

Nursing diagnoses that may appear

1. Imbalanced Nutrition: Less Than Body Requirements
2. Risk for Electrolyte Imbalance
3. Activity Intolerance
4. Disturbed Body Image

Nursing Interventions

1. Imbalanced Nutrition: Less Than Body Requirements

NOC: After nursing actions are fulfilled, the patient's nutritional needs are fulfilled.

Outcomes :

• There is an increase in body weight according to the purpose
• No signs of malnutrition
• No significant weight loss occurred

NIC:

1. Assess for food allergies
2. Monitor for weight loss
3. Give sugar substance
4. Instruct the patient to increase protein and vitamin C
5. Provide information about nutritional needs
6. Collaboration with a nutritionist to determine the number of calories and nutrients a patient needs.

2. Risk for Electrolyte Imbalance

NOC: After nursing, electrolyte balance occurs

Outcomes:

• No signs of dehydration
• Good skin turgor elasticity
• There is no excessive thirst
• Maintain urine output according to age and body weight

NIC:

1. Assess vital signs
2. Monitor hydration status (mucous membrane moisture, adequate pulse, orthostatic blood pressure)
3. Monitor fluid status including fluid intake and output
4. Maintain accurate intake and output records
5. Give IV fluids
6. Push oral input
7. Encourage the family to help patients eat
8. Doctor's collaboration if signs of excess fluid appear to worsen

3. Activity Intolerance

NOC: After nursing actions the client's condition is stable when performing activities

Outcomes :

• Able to do daily activities (ADLs) independently
• Good circulation status
• Vital signs are normal

NIC:

Monitor physical, emotional, social and spiritual responses

1. Monitor adequate nutrition intake as a source of energy
2. Help to choose activities that are consistent with physical, psychological and social abilities
3. Help clients to identify activities that can be done
4. Collaborate with medical rehabilitation personnel in planning appropriate therapeutic programs

4. Disturbed Body Image

NOC: After nursing actions

Outcomes:

• Positive body image
• Being able to identify personal strengths
• Factually describing changes in bodily functions
• Maintaining social interaction

NIC:

1. Assess verbally and non-verbally the client's response to his body
2. Monitor the frequency of self-criticism
3. Explain treatment, treatment of disease
4. Encourage clients to express their feelings
5. Facilitate contact with other individuals in small groups

Bibliography

(Kimberly, 2011) 
(Arif Muttaqin, 2010)
(NEDA, 2012)
(Licino, 1996)
(Jimerson, 1990)
(Stock, 2005)
(Holman, 1995)
(Ringgoti, 1995)
(Kimberly, 2011)
(Wals, 2008)
(Chavez and Insel, 2007) 

Source : https://nandacareplan.blogspot.com/2020/04/nursing-care-plan-for-bulimia-nervosa.html

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

Anxiety related to Premenopausal Syndrome

 

Premenopause is the name given to the time before the cessation of menstruation with decreased estrogen levels, luteal insufficiency, increased gonadotropins and autonomic symptoms (Purwatyastuti, 2007). The term premenopause is still common in the ears, but every woman will definitely experience it. Before reaching menopause, a woman will experience several physical changes and hormonal symptoms, including irregular menstruation.

Premenopause is the period in which the body begins to transition to menopause. This period can last from two to eight years, plus one year at the end of the period leading to menopause. This symptom is natural, because it is a sign and process of stopping the reproductive period.

In this period, generally the level of production of the hormones estrogen and progesterone fluctuates, rises and falls irregularly. Menstrual cycles can suddenly lengthen or shorten. Usually, this premenopause period occurs in their 40s, but many also experience these changes when they are still in their mid-30s.

In relation to the age factor, the capacity for reproduction that takes place during menstruation or the first menstruation still continues regularly. With the cessation of this function will also end the function of service, devotion, and the preservation of the human species. Because with the end of menstruation, the process of ovulation or fertilization of the egg also stops because of it. Then all the glandular apparatus experience obstacles and reduce their activity. In addition, the genital organs also undergo an atrophic process, which is to become shriveled and function backwards. Finally, all parts of the body gradually show signs of aging. This phase in women is called menopause (Kartini Kartono, 2007).

Some women who experience premenopause think this condition is part of their life cycle, but many women complain that with the arrival of premenopause they will become anxious because premenopausal syndrome is often associated with anxiety in dealing with a situation that was previously unworried. This condition is because women who face premenopause generally do not get the correct information or knowledge so that what they imagine is the negative effects that will be experienced after entering the premenopause and menopause periods.

Premenopausal syndrome is experienced by many women almost all over the world.

To find out the symptoms of premenopausal syndrome and get rid of anxiety and worries when entering the premenopausal period is to recognize the signs of premenopausal syndrome as early as possible. Living a healthy life by consuming healthy food, drinks, regular exercise and adequate rest, is the capital for a pleasant menopause period, besides that, it is necessary to have a Pap smear, colposcopy, breast self-examination, mammography, colon cancer examination, laboratory tests, osteoporosis tests. (Proverawati, 2010)

Based on Larasati's research (2012), in some cases women who experience menopause begin to withdraw from social interactions because they feel they have no value and feel useless. Such as limiting social interaction with friends and family. They prefer to be alone away from the crowd. Women who experience menopause will need family and closest friends as support so they are not inferior in adapting to their environment. In addition, there is motivation from him to live his life with enthusiasm (good quality of life), to become a good quality of life that needs to be done, namely maintaining health by eating vegetables, consuming vitamins and exercising, regulating sleep patterns of at least 8 hours per day, reducing heavy work and do light things, and reduce emotions so as not to get angry easily. While Notoatmodjo (2007) knowledge that a person has influences his behavior, the better a person's knowledge, the better his behavior will be and knowledge itself is influenced by the level of education, sources of information and experience.

Disturbed Sleep Pattern - Insomnia related to Fear and Anxiety

 Source : https://nandacareplan.blogspot.com/2021/08/anxiety-related-to-premenopausal.html