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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Appendectomy - Nursing Care Plan for Preoperative and Postoperative

Definition of Appendicitis

Appendicitis is an inflammation that often occurs in the appendix which is a serious case of abdominal surgery are the most common.


Appendectomy

An appendectomy is the surgical removal of the vermiform appendix. This procedure is normally performed as an emergency procedure, when the patient is suffering from acute appendicitis. In the absence of surgical facilities, intravenous antibiotics are used to delay or avoid the onset of sepsis; it is now recognized that many cases will resolve when treated perioperatively. In some cases the appendicitis resolves completely; more often, an inflammatory mass forms around the appendix, causing transruptural flotation. This is a relative contraindication to surgery.


Etiology of Appendicitis

Appendicitis is a bacterial infection caused by obstruction or blockage due to:

1. Hyperplasia of lymphoid follicles
2. Fecalith presence in the lumen of the appendix
3. Appendix tumor
4. The presence of foreign objects such as ascariasis worm.
5. Appendix mucosal erosion due to parasites such as: E. Histilitica.

According to research, epidemiology suggests eating foods low in fiber will cause constipation which can cause appendicitis. This will increase intra-caecal pressure, causing a functional obstruction appendix and increase the growth of germs in the colon flora.


Pathophysiology of Appendicitis

Signs and Symptoms of Appendicitis

Pain, felt in the lower abdominal quadrant and is usually accompanied by mild fever, nausea, vomiting and loss of appetite. Local tenderness at the point Mc. Burney, when done pressure. Tenderness may be found out.

The degree of tenderness, muscle spasm, and whether there is constipation or diarrhea does not depend on the severity of infection and location of the appendix. If the appendix at the back of the cecum circular, pain and tenderness can be felt in the lumbar region; when one end was in the pelvis, these signs can only be known on rectal examination. Pain on defecation shows that the tip of the appendix is close to the bladder or ureter. The existence of muscle stiffness in the bottom right of the rectum may occur.

Rovsing sign can arise with left lower quadrant palpation, which causes pain felt in the lower right quadrant. If the appendix has ruptured, the pain can be more spread out; abdominal distension due to paralytic ileus and the client's condition worsened.


Complications of Appendicitis

The main complication of appendicitis is perforation of the appendix, which can lead to peritonitis or abscess. The incidence of perforation is 105 to 32%. The incidence is higher in young children and the elderly. Perforation generally occurs 24 hours after the onset of pain. Symptoms include a fever with a temperature of 37.7 ° C or higher, continuous abdominal tenderness.


Management of Appendicitis

In acute appendicitis, the best treatment is surgery the appendix. Within 48 hours must be performed. Patients in the observation, rest in Fowler's position, given antibiotics and given food that does not stimulate peristalsis, if there is perforated drain given the lower right stomach.

1. Preoperative Appendectomy, including patients in hospital, given antibiotics and compress, to reduce the temperature of the patient, the patient is asked to bed rest and fasted.
2. Operative action; Appendectomy
   
3. Postoperative Appendectomy, one day post surgery clients are encouraged to sit upright in bed for 2 x 30 minutes, the next day soft food and stand upright outside the room, the seventh day stitches removed, the client's home.

Nursing Care Plan Appendicitis

Nursing Assessment

1. The identity of the client
2. History of Nursing
   
   • Current medical history; complaints of pain in postoperative wound appendectomy, nausea, vomiting, increased body temperature, increased leukocytes.
   • Past medical history
3. Physical Examination
   
   • Cardiovascular System: To determine vital signs, presence or absence of jugular venous distension, pallor, edema, and abnormal heart sounds.
   • Hematologic System: To determine whether there is an increase in leukocytes is a sign of infection and bleeding, nosebleeds splenomegaly.
   • Urogenital System: Whether or not the tension of the bladder and lower back pain complaints.
   • Musculoskeletal System: To determine whether there is difficulty in movement, pain in bones, joints and there is a fracture or not.
   • The immune system: To determine whether there is lymph node enlargement.
4. Investigations
   
   •   Routine blood tests: to determine an increase in leukocytes is a sign of infection.
   •   Abdominal examination photo: to know the existence of post-surgical complications.

Nursing Diagnosis Preoperative and Postoperative Appendectomy

Preoperative Appendectomy

1. Risk for deficient fluid volume related to preoperative vomiting.

2. Acute pain related to distention of the intestinal tissue by inflammation.

3. Anxiety related to change in health status.

Postoperative Appendectomy

1. Acute pain related to the presence of postoperative wound appendectomy.

2. Impaired nutrition less than body requirements related to reduced anorexia, nausea.

3. Risk for infection related to surgical incision.

4. Deficient knowledge: about the care and diseases related to lack of information.


Nursing Interventions


1. Preparation of general surgery

This can be done by the nurse when the client entered the operating room nurse before surgery:

• Introducing the client and close relatives of hospital facilities to reduce the anxiety of clients and their relatives (the orientation of the environment).
• Measuring vital signs.
• Measure weight and height.
• Collaboration is an important laboratory tests (hematocrit, serum glucose, Urinalisa).
• The interview.

2. Preoperative Interventions

• Observation of vital signs
• Assess fluid intake and output
• Auscultation of bowel sounds
• Assess the status of pain: the scale, location, characteristics
• Teach relaxation techniques
• Give fluids intervena
• Examine the level of anxiety
• Give information about the disease process and actions

PostoperativeIinterventions

• Observation of vital signs
• Assess the scale of pain: characteristics, scale, location
• Assess the state of the wound
• Advise to change position as tilted to the right, left and sat down.
• Assess nutritional status
• Auscultation of bowel sounds
• Give wound care information and disease.

Evaluation

1. Impaired sense of comfort: pain is resolved
2. No infection
3. Overcome nutritional deficiencies
4. The client understands about care and illness
5. Weight loss does not occur
6. Vital signs within normal limits

 Raed More : https://nursing-care-plan.blogspot.com/2011/11/nursing-care-plan-for-preoperative-and.html

Nursing Care Plan for Chronic Obstructive Pulmonary Disease (COPD) with 10 Nursing Diagnosis

Chronic Obstructive Pulmonary Disease (COPD) is a chronic lung disease is progressive, meaning the disease lasts a lifetime and is slowly deteriorating from year to year. In the course of this disease there are phases of acute exacerbation. Various factors play a role in the course of the disease, among other risk factors are factors that cause or exacerbate illnesses such as smoking, air pollution, environmental pollution, infection, genetic and weather changes.

The degree of airway obtruksi happened, and identification of components that allow for reversibility. Stage of the disease outside the lung and other diseases such as chronic sinusitis and pharyngitis. That ultimately these factors make further deterioration occurs sooner. To perform the management of COPD should consider these factors, so that the treatment of COPD for the better.

Chronic obstructive pulmonary disease is a broad classification of disorders that includes chronic bronchitis, bronchiectasis, emphysema and asthma, which is an irreversible condition associated with dyspnea on exertion and decreased air flow in and out of the lungs.

Chronic obstructive pulmonary disease is a lung disorder characterized by impaired lung function in the form of prolonged expiratory period caused by the narrowing of the airways and not much changed in the period of observation for some time.

Signs and symptoms will lead to two basic types:

• Have a dominant direction of the clinical picture of chronic bronchitis (blue bloater).
• Have a clinical picture towards emphysema (pink puffers).

Signs and symptoms are as follows:

• body weakness
• cough
• shortness of breath
• Shortness of breath on exertion and breath sounds
• wheezing
• prolonged expiratory
• form the barrel chest (Barrel Chest) in advanced disease
• the use of accessory muscles
• decreased breath sounds
• sometimes found paradoxical breathing
• leg edema, ascites and clubbing

10 List of Nanda Nursing Diagnosis for COPD

1. Ineffective airway clearance related to: bronchoconstriction, increased sputum production, ineffective cough, fatigue / lack of energy, bronchopulmonary infection.
2. Ineffective breathing pattern related to: shortness of breath, mucus, bronchoconstriction, airway irritants.
3. Impaired gas exchange related to: ventilation perfusion inequality.

4. Activity intolerance related to: imbalance between oxygen supply with demand.
5. Imbalanced Nutrition: less than body requirements related to: anorexia.
6. Disturbed sleep pattern related to: discomfort, sleeping position.
7. Bathing / Hygiene Self-care deficit related to: fatigue secondary to increased respiratory effort and ventilation and oxygenation insufficiency.
8. Anxiety related to: threat to self-concept, threat of death, purposes that are not being met.
9. Ineffective individual coping related to: lack of socialization, anxiety, depression, low activity levels and an inability to work.
 10. Deficient Knowledge related to: lack of information, do not know the source of information.

Read More : https://nursing-care-plan.blogspot.com/2011/12/nursing-care-plan-for-chronic.html