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 Due to low self-esteem and lack of social activity, clients become withdrawn from the environment.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.

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