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

The Process of Headache and Dizziness


Headache is a condition there is pain in the head. The pain can occur in the whole head, only felt in most of the head, neck, back to back.

Headaches arise as a result of stimulation of the parts in the head and neck region are sensitive to pain. And these parts are muscles occipital, temporal, and frontal scalp, subcutaneous arteries and periosteum (extra cranial). The bones of the skull are not sensitive to pain. Part intracranial (in the head) are sensitive to pain including meninges, especially the basal dura, and the meninges which protects the sinus venosus and large arteries at the base of the brain. Most of the brain tissue itself is not sensitive to pain.

Stimulation of these parts can be:
  • Infection of the lining of the brain: meningitis, encephalitis.
  • Chemical irritation of the lining of the brain like a subdural hemorrhage or after pneumo, or substances contrast-encephalography.
  • Stretching lining of the brain due to the intracranial space persisted, liquor traffic obstruction, venous sinus thrombosis, cerebral edema, or intracranial pressure decreases drastically and suddenly.
  • Intracranial arterial vasodilation due to toxic state (as in the general infection, alcohol intoxication, CO intoxication, allergic reactions), metabolic disorders (such as hypoxemia, hypoglycemia, hypercapnia), the use of vasodilator drugs, after the state of cerebral contusion, acute cerebrovascular insufficiency, blood pressure systemic jumped suddenly.
  • Extracranial vascular disorders, such as vasodilation (migraine, and 'cluster headache') and inflammation (temporal arteritis).
  • Radiation of pain ("Referred pain ') from the eye (glaucoma, iritis), sinuses (sinusitis), cranial base (ca. nasopharyngeal), teeth (molars II pulpids and urgent dental), and the neck area (spondiloartitis, cervical deformans ).
  • Muscle tension-drug head-neck-shoulder as a manifestation of organic psycho in a state of depression and stress.


Dizziness is a term that most people use to describe the state of a headache. In medical science dizziness and headache is a condition that is different, in terms of perceived symptoms, the disease causes, and treatment.

Dizziness and vertigo are two types of sensory disturbance of balance that needs to be distinguished. When the body was floating, swaying, rocking, it is a picture that is in accordance with the 'dizzy'. Then, if you feel swirling body or objects around a rotating body, or lying around the body is a picture of 'vertigo'.

The basis of vertigo is interference with the body's equilibrium. While dizziness does not always point to the disruption of the body as a means of balancing the cause. This is a chaotic feeling dizzy in the head. For example, someone who was thinking about a lot of issues surrounding the business and noisy. For an uneasy feeling in the head, as if lack of sleep, want to get the flu, is often also used the term dizziness, which is not merely a balance disorder.

Definition of Unstable Angina Pectoris

Angina pectoris is chest discomfort as a result of myocardial ischemia without infarction. Clinical classification of angina basically useful for evaluating the mechanism of ischemic. Unstable angina pectoris is a clinical syndrome that dangerous and is a type of angina pectoris that can turn into a myocardial infarction or death.

Unstable angina pectoris syndrome has long been known as an early symptom of acute myocardial infarction (AMI). Many studies have reported that unstable angina pectoris is a risk for the occurrence of AMI and death. Several studies have shown that 60-70% of patients with AMI and 60% of patients with a history of sudden death in illness with symptoms of unstable angina pectoris. While the long-term research to get AMI occurs in 5-20% of patients with unstable angina pectoris with a mortality rate of 14-80%.

In the group with chest pain, there is a heart attack two times greater in number than those who did not experience chest pain. In the group who experience angina and possible heart attack before (they admitted had experienced at least one severe attack of chest pain, which lasted longer than usual, even at rest), there are more than six times the heart attack compared to other groups.

Unstable angina pectoris, located between the spectrum of stable angina pectoris and myocardial infarction, so it is a challenge in preventing the occurrence of myocardial infarction.

Definition of Unstable Angina Pectoris

Angina pectoris is a clinical syndrome in which the client had an attack of typical chest pain, namely; like pressure, or feel heavy in the chest, often radiating to the left arm which arise during and immediately lost activity when the activity stops. (Anwar, Bahri, 2009)

10 Common Symptoms of Dementia - Alzheimer's Disease

Dementia, including Alzheimer's disease that affects memory, thinking, behavior and emotion, is one of the challenges of the largest global public health issues.
In about 1950, estimated 2.5 million people worldwide suffer from this disease, and reached six billion people in 2000. World Health Organization, WHO, estimates that more than one billion people aged older than 60 years or 10 percent of the world's population suffer from Alzheimer's Disease in 2003.

If your family members show the following symptoms, immediately consult a doctor.

1. Impaired memory.
Often forgotten the events that had just happened, forget appointments, asking and telling the same thing over and over again, forgetting the parking lot (in the high frequency).

2. It is difficult to focus.
Difficult to perform activities of daily work, forgot how to cook, operate the telephone, cell phone, can not do simple calculations, work with a longer time than usual.

3. Difficult familiar activities.
It is often difficult to plan or complete everyday tasks, confused how to drive, difficult to manage finances.

4. Disorientation
Confused about the time (day / date / day is important), confused on where they are and how they got there, do not know the way back home.

5. Difficulty understanding visuospatial.
It is hard to read, measure distances, determine the distance, distinguish colors, does not recognize his own face in the mirror, the mirror crashed while running, pour the water in the glass, but spill and improper pour.

6. Communication Disorders.
Difficulty speaking and looking for the right word, often stopping in the middle of a conversation and confused to continue.

7. Put the items are not in place
Forget where to put something, even sometimes suspect that steal or hide the goods.

8. False make decisions
Dressed in mismatched, for example wearing a red shirt left foot, right foot blue shirt, can not take into account the payment in the transaction and can not care for themselves well.

9. Withdraw from association
Do not have the spirit or the initiative to do activities or hobbies that used to enjoy, not too excited to hang out with his friends.

10. Changes in behavior and personality
Emotions changed drastically, become confused, suspicious, depressed, fearful or excessive depending on family members, easily frustrated and discouraged both at home and at work.

Dementia Nursing Assessment

Dementia Nursing Diagnosis, Outcome, Interventions and Evaluation

Dementia Treatment

Nursing Assessment for Hypothermia and Hyperthermia

Hypothermia and Hyperthermia (Nursing Assessment)

Hypothermia is a condition where the body's mechanism for temperature regulation difficulties to overcome the pressure of cold temperatures. Hypothermia can also be defined as the temperature of the inside of the body below 35 ° C. The human body is able to regulate the temperature in termonetral zone, which is between 36.5 to 37.5 ° C. Outside this temperature, the response of the body to regulate temperature will be active balancing heat production and heat loss in the body.

Hyperthermia is an increase in the core temperature of the human body that usually occurs due to infection. Hyperthermia can also be defined as a body temperature that is too hot or high. Generally, people will sweat to lower body temperature. However, in certain circumstances, the temperature can rise quickly up spending the sweat does not provide sufficient effect.

Nursing Assessment for Hypothermia and Hyperthermia

1. History of pregnancy
  • Labor difficulties with infant trauma
  • Drug abuse
  • The use of anesthesia or analgesia in women
2. The status of newborn
  • Prematurity
  • Apgar scores were lower
  • Asphyxia with resuscitation
  • CNS abnormalities or damage
  • Body temperature below 36.5 C or above 37.5 C
  • Maternal fever that precipitate neonatal sepsis
3. Cardiovascular
4. Gastrointestinal
  • Poor food intake
  • Vomiting or abdominal distension
  • Losing weight means
5. Integumentary
  • Central cyanosis or pallor (hypothermia)
  • Skin redness (hyperthermia)
  • Edema of the face, shoulders and arms
  • Cold on the chest and extremities (hypothermia)
  • Perspiration (hyperthermia)
6. Neurologic
  • Weak cry.
  • Decreased reflexes and activity
  • Fluctuations in temperature above or below the normal range according to age and weight
7. Pulmonary
  • Nasal flaring or decreased breath, iregguler
  • Chest retraction.
  • Expiratory grunting.
  • Episodes of apnea or tachypnea (hyperthermia)
8. Renal
  • Oliguria.
9. Diagnostic Study
  • Serum glucose levels, to identify the decrease in energy used due to the response to cold or heat.
  • Blood gas analysis, to determine the increase in carbon dioxide and oxygen levels decrease, indicating the risk of acidosis.
  • Blood Urea Nitrogen levels, indicating an increase in impaired kidney function, and potential oliguric.
  • Study electrolyte, to identify an increase in potassium associated with impaired renal function.
  • Culture of body fluids, to identify the presence of infection.

Mesothelioma Diagnosed

Nursing Diagnosis for Mesothelioma
  1. Ineffective airway clearance
  2. Ineffective breathing pattern
  3. Pain
  4. Impaired gas exchange
  5. Impaired physical mobility
  6. Anxiety
  7. Excess fluid volume
  8. Fatigue
  9. Hopelessness
  10. Impaired skin integrity
  11. Risk for infection

Nursing Interventions for Mesothelioma
  1. Monitor respiratory status, Provide oxygen as ordered.
  2. Assist the patient to a comfortable position (Fowler's position, for example)
  3. Provide action for patient comfort: Such as repositioning and relaxation techniques.
  4. Provide treatment to reduce pain, according to therapy programs. Monitor and document the medication's effectiveness.
  5. If mobility decreases, turn the patient frequently. Provide skin care, particularly over bony prominences. Encourage him to be as active as possible.
  6. Monitor I.V. fluid intake to avoid circulatory overload and pulmonary congestion.
  7. Monitor vital signs: blood pressure, respiration, pulse, body temperature.
  8. Teach relaxation techniques.
  9. Teach breathing and positioning variations to ease the dyspnea associated with progressive disease

Nursing Diagnosis, Nursing Interventions NCP for Mesothelioma

Assessment, Physical Examination and Data Analysis - Nursing Care Plan for Heart Failure

Nursing Care Plan for Heart Failure


Assessment is the basic thinking and the nursing process which aims to collect data and information or data about the client in order to identify, recognize the problems of health and nursing needs of clients both physically, mentally, socially and environmentally. Systematic assessment in nursing in the four phases of activities which include: data collection, problem determination, problem analysis, evaluation. (Effendi Nasrul, 1995: 8).

1. Biodata
  • Name: to distinguish between patients with one another.
  • Age: heart failure usually occurs at the age above 50 years, with age, the body's organs function will decline. Including blood vessels, prone to atherosclerosis. But it could happen at the age of children due to congenital valvular abnormalities.
  • Gender: a greater risk of heart failure in men due and proportion of the heavier work, stress and smoking activities.
  • Tribe / nation: Africans (blacks) with hypertension have a 2-3 times higher risk of heart failure compared to whites. (Lestari Indah, 2002: 55).

2. The main complaint and history of present illness
  • Shortness of breath (dyspnea) due to fluid accumulation in the lungs because of left ventricular ineffective causing shortness.
  • Paroxysmal nocturnal dyspnea (or PND) (wake up at midnight the day because of difficulty breathing) caused by reabsorption of fluid in the lungs.
  • Fatigue: due to a decrease in cardiac output which causes depletion of ATP as an energy source for the contraction of the tool.
  • Ascites: due to accumulation of fluid in the abdominal cavity due to increased portal vera boosting serous fluid in and out and the portal circulation.

3. Past medical history
  • Congenital heart valve damage.
  • Hypertension (increase cardiac work and influence the process of atherosclerosis.
  • DM (Diabetes Mellitus).
  • Cardiac surgery.
  • Chronic myocardial infarction.

4. The family medical history
  • Children and parents with a history of heart disease or other persons are more susceptible to the same case.

5. Psychological and spiritual history

  • Experienced psychological history can continuously improve the work of the heart.
  • Spiritual clients can improve coping clients in overcoming anxiety.

6. The pattern of daily habits
  • Nutrition: Eat foods that contain a lot of cholesterol and fatty acid burn, causing atherosclerosis and increases blood pressure. Drinking coffee (caffeine) and alcohol which made the work of the heart.
  • Elimination: Nacturia: a decrease in urine output.
  • Activities and exercises: Fatigue (easily tired).
  • Rest and sleep: It's hard to sleep because of shortness of breath.

Assessment, Physical Examination and Data Analysis - Nursing Care Plan for Heart Failure
Physical Examination

1. General condition:
  • Awareness: (Compos Metis up to coma).
  • Weak.
  • Anxiety.
  • Cyanosis.
2. Vital signs
  • Tension: increased.
  • Pulse: increased.
  • Temperature: normal or increased.
  • Respiratory: increased and irregular.
3. Weight: may increase if edema.

4. Pemeriksaansaan cephalocaudal:
  • Head and neck:
  • Konjuctiva pale jugular vein enlargement,
  • There are signs of anemia,
  • Dry lips, cyanosis.

5.Thorax examination:
  • Dipsnea, tachipnea, orthopnea.
  • Breathing chyene - Stokes (irregular).
  • Intercostal retractions.
  • Ronkhi, whezzing.
  • Tachicardia.
  • Increased blood pressure.
6. Abdominal examination:
  • Ascites (fluid).
  • Tenderness.
  • Hepatomegaly.
7. Integumentary inspection and nails:
  • Peripheral cyanosis.
  • Pale.
  • Cold acral.
8. Examination extremities:
  • Ektrimitas peripheral cyanosis.
  • Limb edema.
9. Examination of genitalia, anus:
  • Edema of the genitalia and the sacrum.
10. Supporting investigation:
  • Laboratory examination or diognastik.
  • ECG examination.
  • Echocardiagrafi examination.

Data Analysis

Analysis of the data is the ability to associate data and linking these data with the concepts, theories and principles relevant, to make inferences in determining the client's health and nursing. Data analysis is a process that includes data validation. Grouping the data into two, namely the subjective data and objective data. Based on the needs of bio-psycho, social and spiritual, compared with the standard and make conclusions about the gap (nursing problems) were found (Nasrul Effendi, 1995: 23,24).

11 Symptoms of Schizophrenia You Need to Know

Schizophrenia. Disorders that we now know as schizophrenia is rampant discussed in public. However, many of us do not know what exactly schizophrenia. In some cases, people with this disorder considered to be possessed by demons, fear, tortured, exiled or even locked up forever.

Like most other mental disorders, the cause of schizophrenia is still not clearly presented. Most people imagine schizophrenic as a person vulnerable to violence or uncontrolled attitude.

One of the most obvious kind of damage caused by schizophrenia involves how a person thinks. Individuals may lose the capacity to think rationally in evaluating the environment and how to interact with others. They often believe things that are not true, and may have difficulty accepting what they see as reality "true".

Schizophrenia is often include hallucinations and / or delusions, which reflects the distortion in the perception and interpretation of reality. Nearly a third of those diagnosed with schizophrenia will attempt suicide. Approximately 10 percent of those diagnosed with this disorder will commit suicide within 20 years from the beginning of this disorder.

Patients with schizophrenia may not share their suicidal thoughts with others. The risk of depression would require special attention because of the high rate of suicide in patients with this disorder. They also often do things that are considered strange by others.

For example, people with schizophrenia, paranoid can act like buying a few key to their door, always look back every time walk in public, and refused to talk on the phone.

This behavior may be considered unreasonable and illogical. However, for those who suffer from schizophrenia, this behavior may reflect a natural reaction on their false beliefs about other people out there who want to do evil to them.

Incidence of schizophrenia in most emerging gradually that generally occurs in early adulthood stage - usually in the early 20s. Relatives and friends are able to see the early warning signs long before the major symptoms of schizophrenia occur in patients. During the initial phase, a person may appear not to have a purpose in life, became increasingly eccentric and unmotivated. They will isolate themselves and start to avoid family and their friends.

Here are the signs that indicate a person experiencing schizophrenia, as reported
  1. Self isolating or withdraw from social interaction.
  2. Irrational, say or believe anything strange or odd.
  3. Increased paranoid or questioning the motives of others.
  4. Easy emotion.
  5. Hostility or suspicion.
  6. Increased dependence on drugs or alcohol (in an attempt to self-medicate).
  7. Lack of motivation.
  8. Speaking in a strange way not like themselves.
  9. Often laugh at inappropriate times.
  10. Insomnia or sleeplessness.
  11. The decline in personal appearance and hygiene.
Although there is no guarantee that someone who experienced one or more symptoms suffered from schizophrenia, eleven sign above could be a reference to identify whether there is a disorder that affects a person.

9 Tips to Avoid Headaches

9 Tips to Avoid Headaches

Headache is a disease that must have been suffered by everyone. Ranging from mild headache, migraine, until a severe headache. Headaches are very disturbing daily activities if not treated immediately.

From now find out what the cause of the headache and begin seriously to stop the pain that is very annoying. Here are 10 steps that can be taken to reduce the risk of headaches:

1. Identify the trigger
You can record why you headaches on that day. Starting from what you eat, to what you are doing because some foods can trigger headaches. After knowing what triggers headaches, you can take steps to avoid it.

2. Reduce stress
You may not be able to avoid stress, but you can reduce it. Perform relaxation with slow rhythmic play cassettes, massage, or bath with aromatherapy.

3. Keep your eyes
Too long in front of computers and televisions can also cause eye fatigue and headache triggers.

4. Eat regularly
Eat regularly with nutrients that are rich in carbohydrates and vitamins, but low in fat. And do not forget to consume a lot of water to avoid dehydration.

5. Regular Sleeping
Sleep at least 8 hours a day so that the body gets a chance to replace cells that have been damaged or dead.

6. Familiarize upright body position
Incorrect posture when sitting or doing activities can cause muscle stiffness, neck and shoulders which then triggers the tension in the head.

7. Stop Smoking
Smoking is a risk factor for several types of headaches. Even cigarette smoke can trigger a headache for some people

8. Exercise regularly
With exercise, toxins and residual substances in the body can be released through sweat.

9. Avoid drug dependence
If you have been taking high doses of medication headaches 2-3 times a week but you still frequent headaches arise, better consult your doctor.

Pathophysiology of Diabetic Ulcers

Diabetes makes disorders / complications through damage to blood vessels throughout the body, called diabetic angiopathy. The disease runs a chronic and is two large vascular disorders (macrovascular) called macroangiopathy, and the small blood vessels (microvascular) called microangiopathy. If the affected blood vessels in the brain arise stroke, blindness occurs when the eye, the heart of coronary heart disease which can lead to heart attack / myocardial infarction, the kidneys become chronic kidney disease to end stage renal failure and should be dialysis or transplantation. When on foot injuries occur that are difficult to heal up into decay (gangrene). Moreover, if the affected nerve arises diabetic neuropathy, so there are parts that do not taste anything / numbness, though needles / spikes or exposed to hot objects.

Abnormalities of the lower limbs due to diabetes caused by vascular disorders, neurological disorders, and infection. In vascular disorders, feet can hurt, if tangible feel cold, if there are wounds are difficult to heal because blood flow to the parts have been reduced. Examination difficult palpable pulse in the legs, the skin appears pale or bluish, then eventually can become gangrenous / tissue decay, then infected and bacteria thrives, it will be dangerous for patients because the infection can spread throughout the body (sepsis). In the event of a nervous breakdown, called diabetic neuropathy may arise taste disorders (sensory) numbness, lack of taste to numbness. In addition, motor disturbances, muscle weakness arises, decreases muscle, muscle cramps, tiredness. Legs that do not taste would be dangerous because when stepping on sharp objects will not be felt when it had been incurred injuries, coupled with the ease of infection. If it's gangrene, legs should be cut in the upper part of the rot.

Diabetic gangrene is a long-term impact of arteriosclerosis and small thrombus embolism. Diabetic angiopathy almost always also lead to peripheral neuropathy. Diabetic neuropathy is a disruption of motor, sensory and autonomic, each of which plays a role in the occurrence of foot injuries. Paralysis of the leg muscles leads to changes in the balance of the foot joints, changes in gait, and will lead to new pressure points on the soles of the feet, causing a callus on the spot.

Sensory disturbance causes local numbness and loss of protection against trauma, so people were injured unnoticed. As a result, the callus can turn into ulcers which when coupled with the infection developed into cellulitis and ended up with gangrene.

Autonomic nerve disorder that results in loss of skin secretions dry skin and easy bruising are difficult to heal. And wound infections are difficult to heal and prone to necrosis resulting from three factors. The first factor is angiopathy arterioles causing poor tissue perfusion feet so that the mechanism of inflammation so ineffective. The second factor is the blood sugar environment fertile for the development of pathogenic bacteria. The third factor is the opening of the artery-vein bypass in subcutaneous, nutrient flow will bypass the site of infection in the skin.

Typical Complaint in Patients with Acute Myocardial Infarction (AMI)

Typical complaint is retrosternal chest pain, such as squeezing, pressure, plugging, heat or crushed heavy objects. The pain may spread to the arms (usually the left), shoulders, neck, jaw and even to the back and epigastrium. The pain lasts longer than angina pectoris and unresponsive to nitroglycerin. Sometimes, especially in diabetic patients, and the elderly, found no pain at all. The pain can be accompanied by nausea, vomiting, spasms, dizziness, sweating, palpitations or syncope. Patients often looked frightened. Although AMI can be the first manifestation of coronary heart disease, but if history is done carefully it is often actually been preceded by complaints of angina, an uneasy feeling in the chest or epigastric.

Abnormalities on physical examination no specific and can be normal. Can be found the S2 heart sounds are broken, paradoxical and gallop rhythm. Crepitation basal showed lung dam. Tachycardia, pallor, cold and hypotension are found in relatively more severe cases, sometimes found pulsation dyskinetic-looking or are in the inferior wall of the chest at the IMA.

Although the majority of individuals do not show obvious signs of myocardial infarction, clinical manifestations usually include:
  • Sudden chest pain.
  • Nausea and vomiting.
  • Feeling weak.
  • Cold and pale skin.
  • A decrease of urine.
  • Tachycardia due to the increase.
  • Sympathetic stimulation of the heart.
  • Anxious.
  • The pain may spread to the arms (generally to the left), shoulders, neck, jaw, and even to the back and epigastrium.
  • The pain lasts longer than usual angina pectoris and unresponsive to nitroglycerin.

Anyone who had a heart attack will feel the complaints are of course different, but generally a person will feel some specific things like:
  1. Chest pain, muscle where lack of blood supply (called ischemia conditions) that affect the need of oxygen by the muscles is reduced. The result is excessive metabolism causing cramps or spasms. Pain is felt in the center of the chest, it can spread to the back of the chest, to the left of the base of the neck, shoulders and upper arms and left hand. Some patients may experience abdominal pain upper part (the base of the center rib and even part of the stomach), where the pain is more severe and does not disappear despite being rested or given cardiac pain medication (nitroglycerin). This is called angina, patients feel uneasy with tightness in the chest and like to feel chest knead.
  2. Shortness of breath, usually felt by people who have heart failure. Tightness is a result of the entry of fluid into the air cavities in the lungs (pulmonary congestion or pulmonary edema).
  3. Fatigue or tiredness, Abnormalities of the heart can cause heart pumping that was not optimal. As a result, the blood supply to the muscles of the body while doing the activity will be reduced, This causes the patient to feel weak and tired. Such symptoms are mild, people just trying to reduce its activity and assume that it is only the aging process.
  4. There is a feeling of pounding (palpitations).
  5. Dizziness and fainting, It can be an early symptom of patients with coronary heart disease. Where decreased blood flow due to rate or abnormal heart rhythm or for worse pumping ability, can cause dizziness and fainting.
  6. Bluish on the lips, fingers and toes as a sign of inadequate blood flow throughout the body.
  7. Sudden cold sweat, and others such as nausea and anxiety.

Signs of a heart attack:
  1. Sense depressed (feels crushed heavy burden, pain, pinched and burning) that causes shortness of breath and choking on the neck.
  2. The pain may radiate to the left arm, neck and back.
  3. The pain can last about 15-20 minutes and occurs continuously.
  4. Arise cold sweat, body weakness, heart palpitations and even unconscious.
  5. The pain can be reduced when taking a break, but will gain weight if the patient is on the move.

Nursing Diagnosis for Diabetes Mellitus : Fluid Volume Deficits

Diabetes mellitus (or diabetes) is a chronic, lifelong condition that affects your body's ability to use the energy found in food. There are three major types of diabetes: type 1 diabetes, type 2 diabetes, and gestational diabetes.

Fluid Volume Deficits Definition : Decreased intravascular fluid, interstitial or intracellular.

Defining characteristics :
  • Thirsty.
  • Decreased skin turgor and tongue.
  • Decreased venous filling.
  • Skin and mucous membranes dry.
  • Increased heart rate, decreased blood pressure, decreased volume and pulse pressure.
  • Weight loss is sudden (except the 3rd room).
  • Weakness.

Related factors:
  • Loss of fluid volume.
  • Failure mechanisms of regulation (diabetes insipidus, hyperaldosteronisme).

Goal :
After nursing actions 2x24 hours, expected the patient does not experience pain with indicator :
  • Maintain urine output in accordance with the age and weight, normal urine specific gravity.
  • Blood pressure, pulse, body temperature within normal limits.
  • No signs of dehydration, elasticity good skin turgor, mucous membranes moist, no excessive thirst.
  • Orientation to time and place well.
  • The number and the respiratory rhythm within normal limits.
  • Electrolytes, hemoglobin, Hmt within normal limits.
  • urine pH within normal limits.
  • Intake of oral and intravenous adequate.

  • The patient will have a normal urine concentration.
  • The patient had a hemoglobin and hematocrit within normal limits for the patient.
  • The patient did not experience abnormal thirst.
  • The patient has a balance of intake and output balance within 24 hours.
  • The patient show good hydration.
  • The patient had oral fluid / intravenous adequate.
  • Maintain records accurate intake and output.
  • Monitor the status of hydration (moisture mucous membranes, adequate pulse, orthostatic blood pressure), if necessary.
  • Monitor vital signs every 15 minutes - 1 hour.
  • Collaboration of IV fluids.
  • Monitor nutritional status.
  • Give oral fluids.
  • Encourage families to help patients eat.
  • Collaboration with doctor if signs of excess fluid appears to worsen.
  • Attach the catheter if necessary.
  • Monitor intake and urine output every 8 hours.

Source :

Ineffective Airway Clearance related to Rhinosinusitis

Rhinosinusitis or sinusitis is inflammation of the paranasal sinuses. It can be due to infection, allergy, or autoimmune problems. Most cases are due to a viral infection and resolve over the course of 10 days.

Rhinosinusitis or sinusitis is defined as an inflammation of the mucous membrane that lines the paranasal sinuses and is classified chronologically into several categories:
  • Acute rhinosinusitis — a new infection that may last up to four weeks and can be subdivided symptomatically into severe and non-severe;
  • Recurrent acute rhinosinusitis — four or more separate episodes of acute sinusitis that occur within one year;
  • Subacute rhinosinusitis — an infection that lasts between four and 12 weeks, and represents a transition between acute and chronic infection;
  • Chronic rhinosinusitis — when the signs and symptoms last for more than 12 weeks; and
  • Acute exacerbation of chronic rhinosinusitis — when the signs and symptoms of chronic rhinosinusitis exacerbate, but return to baseline after treatment.
All these types of sinusitis have similar symptoms, and are thus often difficult to distinguish. Acute sinusitis is very common. Roughly ninety percent of adults have had sinusitis at some point in their life.

Nursing Diagnosis for Rhinosinusitis : Ineffective Airway Clearance related to excessive mucus.

  • Respiratory status : Ventilation
  • Respiratory status : Airway patency
  • Aspiration Control
Expected outcomes :
  • Demonstrate effective cough and breath sounds were clean, no cyanosis and dyspnea (able to produce a sputum sample, was able to breathe easily, no pursed lips).
  • Indicates that a patent airway (the client does not feel suffocated, the rhythm of breathing, respiratory frequency in the normal range , no abnormal breath sounds).
  • Being able to identify and prevent the factors that can inhibit airway.


Airway Management
  • Open the airway, use techniques chin lift or jaw thrust if necessary.
  • Position the patient to maximize ventilation.
  • Identification of the patient's need for installation tools artificial airway.
  • Installing mayo if necessary.
  • Perform chest physiotherapy if necessary.
  • Remove secretions by coughing or suctioning.
  • Auscultation of breath sounds, note the presence of additional noise.
  • Perform suction on the mayo.
  • Give bronchodilators if necessary.
  • Give humidifier wet gauze, with NaCl moist.
  • Set intake to optimize fluid balance.
  • Monitor respiration and O2 status.

Airway Suction
  • Ensure the needs of oral / tracheal suctioning.
  • Auscultation of breath sounds before and after suctioning.
  • Inform the client and family about suctioning.
  • Ask the client a deep breath before suction done .
  • Give O2 by using a nasal, to facilitate nasotracheal suction.
  • Use sterile tools every action.
  • Instruct the patient to rest and deep breath, after the catheter is removed from the nasotracheal.
  • Monitor the status of the patient oxygen.
  • Teach the patient's family, how to perform suction.
  • Stop suction and administer oxygen if the patient showed bradycardia, increase in O2 saturation, etc.
Source :

Nursing Care Plan for Hyperthermia related to Dengue Hemorrhagic Fever (DHF)

Dengue hemorrhagic fever is a severe and sometimes fatal infection that occurs tropical regions. The dengue virus is transmitted by mosquitoes. A more severe version of the infection called dengue hemorrhagic fever can involve significant bleeding and a drop in blood pressure that can cause shock and death. This condition is sometimes known as dengue shock syndrome.

Dengue hemorrhagic fever can occur when a person is bitten by a mosquito and exposed to blood infected with the dengue virus. Those who are repeatedly exposed to the dengue virus often experience more acute symptoms and are at risk for dengue hemorrhagic fever.

Nursing Diagnosis : Hyperthermia related to disease process (viremia)

Goal :
Patient 's body temperature can be reduced.

Outcome :
  • Comfortable body condition.
  • Temperature 36,80C-37,50C.
  • Blood pressure : 120/80 mmHg.
  • Respiration : 16-24 x / mnt.
  • Pulse : 60-100 x / mnt.

Intervention :
  • Assess the onset of fever.
  • Observation of vital signs (temperature, pulse, blood pressure, respiration) every 3 hours.
  • Instruct the patient to drink (2.5 liters / 24 hours).
  • Give warm compresses.
  • Suggest to not wear thick blankets and clothing.
  • Give intravenous fluid therapy and medications as ordered.

Rationale :
  • To identify patterns of fever.
  • Vital Signs is a reference to determine the patient's general condition.
  • The increase in body temperature results in increased evaporation body so it needs to be balanced with a high fluid intake.
  • With vasodilation can increase evaporation which accelerates the decline in body temperature.
  • Clothing thin body helps reduce evaporation.
  • Fluid administration is very important for patients with a high temperature.

Source :

Impaired Gas Exchange and Activity Intolerance related to Heart Failure

Nursing Care Plan for Heart Failure

Heart failure or chronic heart failure (CHF), occurs when the heart is unable to pump sufficiently to maintain blood flow to meet the needs of the body. The terms congestive heart failure (CHF) or congestive cardiac failure (CCF) are often used interchangeably with chronic heart failure. Signs and symptoms commonly include shortness of breath, excessive tiredness, and leg swelling. The shortness of breath is usually worse with exercise, when lying down, and at night while sleeping. There is often a limitation on the amount of exercise people can perform, even when well treated.

Heart failure symptoms are traditionally and somewhat arbitrarily divided into "left" and "right" sided, recognizing that the left and right ventricles of the heart supply different portions of the circulation. However, heart failure is not exclusively backward failure (in the part of the circulation which drains to the ventricle).

There are several other exceptions to a simple left-right division of heart failure symptoms. Additionally, the most common cause of right-sided heart failure is left-sided heart failure. The result is that patients commonly present with both sets of signs and symptoms.

Nursing Diagnosis :

1. Impaired Gas Exchange related to changes in the alveolar capillary membrane.
characterized by; dyspnea, orthopneu.

Goal: more effective gas exchange, the results; analysis of blood gases within normal limits and the patient was free from respiratory distress.

Interventions :
  • Auscultation of breath sounds, crackles, wheezing.
  • Instruct the patient to cough effectively and breathe deeply.
  • Keep sitting or bed rest with semifowler position.
  • Collaboration to monitor blood gas analysis and pulse oximetry.
  • Collaboration for the provision of supplemental oxygen as indicated.
  • Collaboration for diuretics and bronchodilators.
Rationale :
  • Monitor the presence of pulmonary congestion for further intervention.
  • Cleaning airway and facilitate the flow of oxygen.
  • Lowers oxygen consumption and maximize lung development.
  • Can be severe hypoxemia during pulmonary edema.
  • Increasing alveolar oxygen concentration to improve tissue hypoxemia.
  • Diuretics can reduce congestion and improve the alveolar gas exchange. Broncodilator for airway dilatation.

Nursing Diagnosis : 

Activity Intolerance related to imbalance between oxygen supply / needs, weaknesses.
characterized by; The patient said wearily continuously throughout the day, shortness of breath on exertion, changes in vital signs during activity.

Goal: Activity achieve optimal limit, as indicated by the patient participating in a desired activity and is able to meet the needs of their own care.

Interventions :
  • Check vital signs before and after the activity.
  • Note the cardiopulmonary response to activity, tachycardia, dysrhythmias, dyspnea, sweating, pale.
  • Provide assistance in self-care activities as indicated. Interspersed periods of activity with periods of rest.
  • Collaboration to implement a cardiac rehabilitation program.
Rationale :
  • Orthostatic hypotension can occur with activity due to the effects of the drug, fluid shifts, influence heart function.
  • The inability of the myocardium, increasing stroke volume during exercise, can increase heart rate, oxygen consumption and increased fatigue.
  • Self care needs without affecting the stress myocardial / excessive oxygen demand.
  • Gradual increase in the activity of the heart and avoid excessive oxygen consumption.

Source :

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