Nursing Care Plan for Activity Intolerance Related To Generalized Weakness

Nursing Care Plan for Activity Intolerance Related To Generalized Weakness

Activity Intolerance related to Generalized Weakness, imbalance between supply and demand of O2.

Goal: Activities of patients are met.

Expected outcomes: Clients can participate in activities at the desired / required, reported an increase in tolerance activity can be measured.


1. Assess the patient's tolerance to the activity by using the parameters: frequency pulse, noted an increase in blood pressure, dyspnea, or chest pain, severe fatigue and weakness, sweating, dizziness or fainting.
R/ : Parameter indicates the patient's physiological response to stress, activity, and indicators of the degree of influence of overwork / heart.

2. Assess readiness to increase the activity, ie a decrease of weakness / fatigue, stable blood pressure, pulse frequency, increased attention to the activities and self-care.
R /: Stability physiological rest is essential to advance the level of individual activities.

3. Encourage promote activity / tolerance of self-care.
R /: myocardial oxygen consumption during various activities can increase the amount of oxygen available. The progress of the activity gradually to prevent a sudden increase in heart work.

4. Provide assistance as needed and encourage the use of bath seats, brushing teeth / hair by sitting and so on.
R /: How energy savings to lower energy use and thus help balance supply and oxygen demand.

5. Encourage the patient to choose the period of participation in the activity.
R /: As the schedule increases tolerance to the progress of the activity and prevent weakness.

Impaired Skin Integrity and Disturbed Body Image related to Blepharitis

Nursing Diagnosis and Interventions for Blepharitis

Impaired Skin Integrity related to inflammatory processes in the skin glands of eyelashes

Goal: Increase in skin integrity repair / healing wounds

with outcomes:
  • The scales are reduced.
  • Itching reduced to disappear.
  • Ulcer condition improved.

  1. Clean the eyelid area regularly and every day.
  2. Use aseptic technique, patient or nurse raised crusting, scaling.
  3. Compress the edge of the eyelid with warm water 3 times or as needed.
  4. Collaboration antibiotics and topical steroids for cases caused by a bacterial infection.

Rationale :
  1. Carefully cleaning each day will keep cleaning the eyelid so that wounds heal faster.
  2. Aseptic technique will prevent more severe irritation / contact with the bacteria.
  3. Compress clean the edge of the eyelid crusting / scaling.
  4. Prevent further infection and reduce inflammation.

Disturbed Body Image related to changes in physical conditions: the lashes fall out and are not replaced with new ones, the yellow crusts.

Goal: The patient does not feel embarrassed and can adjust to the physical condition

with outcomes:
  • Indicates acceptance of the conditions themselves.
  • Actively participate in the therapy program.
  1. Establish a therapeutic relationship between nurses and patients.
  2. Encourage the patient to express feelings.
  3. Identify the role of the patient's problems today.
  4. Encourage the patient to live in recognition of its own.

Rationale :
  • With the therapeutic relationship, the patient will feel appreciated and more open.
  • With storytelling will be able to reduce the burden on the client's feelings.
  • To know the problems of the client.
  • Help improve the confidence of clients.

Nursing Care Plan for Altered Sensory Perception - Hallucinations

Altered Sensory Perception - Hallucinations

Hallucinations is sensory experiences without external stimuli occurs in a state of full consciousness that describes the loss of ability to judge reality. (Sunaryo, 2004)

Hallucinations is perceptions of disorders in which the client perceives something that does not happen, the perception of the senses without any external stimuli. (Maramis, 1998).

Signs and symptoms:
  • Talk, smile, laugh alone.
  • Said listening to the sound, see, taste, breathe and feel an unreal.
  • Damaging own self, others and the environment.
  • Can not distinguish between real and unreal.
  • Unable to focus or concentration.
  • Suspicious and hostile attitude.
  • Discussion chaotic sometimes unreasonable.
  • Pulling away, shy away from others.
  • Difficult to make a decision.
  • Fear.
  • Unwilling to perform self care: bathing, brushing teeth, dressing, decorated with neat.
  • Irritable, annoyed, angry.
  • Self blame themselves, or others.
  • Sometimes angry face pale.
  • Tense facial expressions.
  • Increased blood pressure.
  • Panting breath.
  • Rapid pulse.
  • Lots of sweat.
That cause hallucinations, among others; client withdraws and low self esteem. Due to low self-esteem and lack of social activity, clients become withdrawn from the environment. Further impact the client will be more focused on self-own. Internal stimuli become more dominant than the external stimulus. Clients gradually lose the ability to distinguish internal stimuli with external stumulus.
These conditions lead to hallucinations.

Signs and symptoms:
  • Physical aspects:
  • Eating and drinking less.
  • Less sleep or disturbed.
  • Self-less appearance.
  • Courage less.
  • Emotional aspects:
  • Slurred speech, whining, crying like a child.
  • Feeling ashamed, guilty.
  • Easy to panic and suddenly angry.
  • Social aspects:
  • Sitting alone.
  • Always subject.
  • Looks dreamy.
  • No matter the environment.
  • Shy away from others.
  • Depending on others.
  • Intellectual aspects:
  • Hopeless.
  • Feeling alone, no support.
  • Lack of confidence.
Clients who experience hallucinations can lose control of himself, so it could be a danger to themselves, other people or damage the environment (risk of injuring themselves, others and the environment). This occurs if the hallucinations had to phase IV, where the client is experiencing panic and its behavior is controlled by the content of the hallucinations. Clients really lost the ability assessment of the environmental reality. In this situation the client can commit suicide, kill others even damage the environment.

Signs and symptoms:
  • Red face.
  • Sharp outlook.
  • Tense muscles.
  • High tone.
  • Arguing.
  • Obtrude: rob food, hit if not happy.

Nursing Diagnosis :
  1. Risk for injury: self, others and the environment.
  2. Altered Sensory Perception : hallucinations.
  3. Social isolation: withdrawal.

Decreased Cardiac Output - Nursing Care Plan for Heart Failure

Nursing Care Plan for Heart Failure

Nursing Diagnosis : Decreased cardiac output related to the physiological response of the heart muscle, increase in frequency, dilatation, hypertrophy, or an increase in stroke volume.

  • Cardiac Pump effectiveness
  • Circulation Status
  • Vital Sign Status
Expected outcomes:
  • Vital Signs in the normal range (blood pressure, pulse, respiration).
  • Can tolerate the activity, there is no fatigue.
  • There are no pulmonary edema, peripheral, and no ascites.
  • There is no loss of consciousness.


Cardiac Care
  • Evaluation of chest pain (intensity, location, duration).
  • Note the presence of cardiac dysrhythmias.
  • Note the presence of signs and symptoms of cardiac putput decline.
  • Monitor cardiovascular status.
  • Monitor respiratory status that indicates heart failure.
  • Monitor the abdomen as an indicator of decreased perfusion.
  • Monitor fluid balance.
  • Monitor any changes in blood pressure.
  • Monitor the patient's response to the effects of antiarrhythmic treatment.
  • Set the period of exercise and rest to avoid fatigue.
  • Monitor the patient's exercise tolerance.
  • Monitor the presence of dyspnea, fatigue, tekipneu and ortopneu.
  • Suggest to reduce stress.

Vital Sign Monitoring
  • Monitor BP, pulse, temperature, and respiration.
  • Note the presence of fluctuations in blood pressure.
  • Monitor vital signs while the patient is lying down, sitting, or standing.
  • Auscultation BP in both arms and compare.
  • Monitor BP, pulse, respiration, before, during, and after activity.
  • Monitor the quality of the pulse.
  • Monitor the presence of pulsus paradoxus.
  • Monitor the presence of pulsus alterans.
  • Monitor the amount and heart rhythm.
  • Monitor heart sounds.
  • Monitor the frequency and rhythm of breathing.
  • Monitor lung sounds.
  • Monitor abnormal breathing pattern.
  • Monitor temperature, color, and moisture.
  • Monitor peripheral cyanosis.
  • Monitor the presence of Cushing's triad (widened pulse pressure, bradycardia, increased systolic).
  • Identify the cause of the vital sign changes.

Nursing Assessment for Allergic Contact Dermatitis

Nursing Assessment

Allergic contact dermatitis is an allergic contact dermatitis due to sensitization to a diverse substance causing an inflammatory reaction in the skin for those who have hypersensitivity to allergens as a result of previous exposure. (Dorland, W.A. Newman: 590. 2002)

To set the allergens causing allergic contact dermatitis required careful anamnesis, a complete medical history, physical examination and patch test.

History addressed in addition to the diagnosis as well as to find the cause. Because it is important in determining treatment and follow-up, namely to prevent recurrence. Required patience, thoroughness, understanding and good cooperation with the patient. In history should also be asked history of atopy, course of the disease, work, hobbies, contact history, and treatment was ever given by a physician and performed his own, personal objects include questions about the new clothes, old shoes, cosmetics, sunglasses, and watches as well as other conditions ie general medical history and possible psychological factors.

Physical examination found the presence of erythema, edema and papular followed by the formation of vesicles which if broken will form the moist dermatitis. The lesions usually occur in the place of contact, not demarcated and may extend into the surrounding area. Because some parts of the body very easily sensitized compared to other parts of the body, the regional predilection regional diagnosis would be very helpful in diagnosis.

Criteria for the diagnosis of allergic contact dermatitis are:
  • A history of contact with a material one, but a long, several times or one time but had previously been or frequent contact with similar material.
  • There are signs of contact dermatitis especially in places.
  • There are signs around the place of contact dermatitis and other similar places where contact but lighter and slower onset, the growth after the contact point.
  • Itching.
  • Patch test with material suspected positive results.

Diagnosis is based on a careful diagnosis and careful clinical examination. Questions about the suspected contacts based skin disorder found. For example, there are skin disorders such numularis lesions around the umbilicus form hyperpigmentation, lichenification, with papules and erosion, it is necessary to ask whether the patient wearing pants or head studs fastening plate made of metal (nickel). The data comes from history also includes employment history, hobbies, topical medications that have been used, systemic medications, cosmetics, ingredients known to cause allergies, skin disease ever experienced, as well as skin diseases in the family (eg, atopic dermatitis, psoriasis).

A physical examination is very important, because by looking at the pattern of localization and skin disorders can often be known possible causes. For example, in the armpit by deodorant, at the wrist by watches, and in both legs by shoes. Examination should be performed on the entire surface of the skin, to see the possibility of other skin disorders due to endogenous causes.

Diagnosis is based on history of exposure to an allergen or related compounds, itchy lesions, the distribution pattern suggests dermatitits contact. History should be centered around a common exposure to allergens. To identify the causative agent may be needed work like a good detective.

Nursing Diagnosis and Interventions for Dermatitis

10 Simple Things That Can Cause Headaches

10 Causes of Headaches

The causes of headaches are not only high blood pressure, stress or brain disorders that can lead to headaches, but simple things like perfume or food can cause headaches that interfere.

10 Simple Things That Can Cause Headaches, among others:
  1. Hot air.
  2. Pungent aroma. Like the scent of paint, perfume and some types of flowers.
  3. Hair ties, braid or use a headband that is too tight. Because connective tissue causing scalp tighten.
  4. Excessive physical exercise activity, especially for migraine sufferers.
  5. Movement or posture is wrong. Eg phone clamped between ear and shoulder, sat down with a chair without a back buffer, the visibility is too close or too far away (eg, on a monitor or TV).
  6. Substance tyramine. Or substances contained in the food manufacturing process takes a long time, for example cheese. The longer the food manufacturing process, the more tyramine content. Tyramine are also widely available on alcoholic beverages, and alcohol can also increase blood pressure to the brain that make you more dizzy.
  7. Skip meals. This causes blood sugar levels to decline. On an empty stomach, avoid eating sweet foods, especially sweets, because it will aggravate blood sugar levels. Not to mention in patients with gastritis, late meals can trigger acid reflux and can give the effect of a headache.
  8. Dehydration. Lack of fluids can also have an impact on the balance of the cells in our body, which can give a manifestation of headache.
  9. Cigarette smoke. Nicotine contained therein causes narrowing of blood vessels in the brain. Especially for patients with migraine, the smoke will cause extreme pain, even will also affect the eyes and nose.
  10. Excessive caffeine consumption.

Try to avoid the top 10 causes of headaches off above in your everyday life. As for some of the tips that can be done to prevent the headaches that arise again, is:
  1. Manage your stress well, for example by doing meditation or massage.
  2. Sports. Walking is a fitting choice, as with walking, movement of the hand that rocks will make the neck and shoulder muscles become more relaxed.
  3. Eating regularly will keep your blood sugar levels remain normal.
  4. Physical therapy.

Source : dr. Adhiatma Gunawan

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