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Nursing Care Plan for Nausea and Vomiting

 
Nausea

Nausea is the sensation (feeling) issued a strong food or want to vomit. Usually accompanied by autonomic signs such as hypersalivation, diaphoresis, tachycardia, pallor, and tachypnea, nausea closely related to anorexia. Nausea caused by distention or irritation in any part of the gastrointestinal tract, but can also be stimulated by higher brain centers.

Nausea is a common symptom of digestive disorders, but may also occur in fluid and electrolyte imbalance, infection, metabolic disorders, endocrine, and cardiac maze. Can also be as a result of drug therapy, surgery, and radiation.

Nausea is also common in the first trimester of pregnancy, nausea can arise from intense pain, anxiety, alcohol poisoning, excessive food or digest food or drinks that do not taste good.


Definition of "Vomit" is a discharge of most or all of the stomach contents food into the stomach occurs after a while, accompanied by contraction of the stomach and abdomen. (Vivian Nanny Lia Dewi, 2010)

In a simple sense of Vomiting is spending the stomach contents through the mouth. Another understanding of the vomiting is a discharge of most or all of the stomach contents food into the stomach occurs after a while, with stomach and abdominal contractions. In the first few hours after birth, the baby may experience vomiting mucus, sometimes with a little blood. Vomiting is not uncommon to settle after breast feeding or food, the situation is probably due to irritation of the gastric mucosa by a number of objects that are ingested during childbirth.

Many causes that can lead to vomiting, namely:
  • Virus infection
  • Stress
  • Gestation
  • Drug
  • Myocardial infarction
  • Uremia
  • Other conditions

Therapeutic Intervention

Nausea and vomiting are very few require intervention. However, if left unchecked will lead to dehydration and electrolyte imbalance. Loss of hydrochloric acid from the stomach can cause metabolic alkalosis. Vomiting black, like coffee, showed vomit mixed with blood. Protection of the airway during vomiting are the most important measures to prevent aspiration. Increased risk of aspiration in patients with loss of consciousness, the elderly, and the failure of reflexes. Place the patient in a comfortable position so that vomit out. Beating back while vomiting can lead to aspiration.


Nursing Process in Patients with Nausea and Vomiting

Assessment / data collection
  1. Episodes of nausea and vomiting
  2. Medical condition
  3. Drugs consumed
  4. Treatment is being done
Early signs of fluid loss:
  1. Weakness
  2. Headache
  3. Not be able to concentrate
  4. Postural hypotension
Further signs of fluid loss:
  1. Confused
  2. Oliguria
  3. Skin cool and moist
  4. Chest and abdominal pain


Nursing Diagnosis, Planning, and Implementation

1 . Nausea related to various causes

The desired result :
  • Patients expressed no nausea and vomiting .
  • Odor-free environment , clean so it does not cause nausea .

Interventions :
  1. Give anti- emetic .
  2. Oral care , to reduce emesis and increased comfort .
  3. Explained to the patient to avoid foods that cause or may cause vomiting .

2 . Risk for aspiration related to decreased reflexes or penuruanan awareness

The desired result :
  • Airway and lung sounds clean patient
Iintervention :
  1. Assess whether the patient is in the risk for aspiration .
  2. Place the patient in a position to prevent aspiration .

3 . Deficient Fluid Volume

The desired result :
  • Patient's vital signs within normal limits .

Interventions :
  1. Monitor for signs of hypovolemia to prevent any complications that may occur .
  2. Measure body weight each day .
  3. Monitor intake output , and vital signs , and vital signs , blood pressure ortohstatik .
  4. Give fluids by IV .
  5. Discharge monitoring during treatment to prevent deficit and excess fluid .

Evaluation

Patients showed no nausea, lung sounds clean and normal vital signs .

Imbalanced Nutrition : less than body requirements related to nausea and vomiting

Risk for Fluid Volume Deficit related to Vomiting

Definition and Causes of Congenital Talipes Equinovarus

 
Definition of CTEV (Congenital talipes Equinovarus)

Congenital talipes Equinovarus (CTEV) or so-called Clubfoot is a common term used to describe a common deformity in which the legs changed from its normal position which is common in children. CTEV is covering flexion deformity of the ankle, inversion of the legs, adduction of the forefoot, and media rotation of the tibia (Priciples of Surgery, Schwartz). Talipes derived from the talus (ankle) and pes (foot), suggesting an abnormality in the leg (foot) which causes the sufferer to walk on his ankle. Equinovarus being derived from the word equino and varus (bent towards the inside / medial).

Congenital talipes Equinovarus is a foot deformity in line twisted heel leg and foot plantar flexion experience. This situation is accompanied with a higher edge in the foot (supination) and the shift of the anterior part of the foot so that it rests on the medial axis of the vertical leg (adduction). With this type of foot arch higher (cavus) and foot in an equinus (plantar flexion). Equino congenital talipes varus is a condition in which the foot in plantar flexion position talocranialis, because musculus tibialis anterior is weak, Inversion ankle because musculus peroneus longus, brevis and Tertius weak, subtalar and midtarsal Adduction.


Causes of Congenital talipes Equinovarus
  1. Causes of Congenital talipes Equinovarus until now not known for sure but allegedly are associated with : Persistence of fetal positioning, Genetic, amniotic fluid in the amniotic too little during pregnancy (oligohydramnios), Neuromuscular disorder (sometimes found along with other abnormalities such as Spina bifida or dysplasia of the pelvis). There are several theories that may be linked to CTEV :
  2. Chromosomal theory , among others : germinativum defect of cells that are not fertilized and appear before fertilization .
  3. Embryonic theory , among others : primary defect that occurs in cells that fertilized germinativum (quoted from Irani and Sherman) which implies a defect occurs between conception and 12 weeks of pregnancy.
  4. Autogenic theory, the theory of development is hampered, among other temporary barriers of development that occurs on or around the week of the 7th to the 8th gestation. At this time there is a clear clubfoot deformity, but when these obstacles occur after 9 weeks, there was a clubfoot deformity is mild to moderate. The development of the theory of constraints associated with changes in genetic factors, known as the "Cronon". "Cronon" This is the right time to guide the progressive modification of any structure of the body during development. Therefore, clubfoot occurs due to disruptive elements (local and general) that cause changes in genetic factors (cronon).
  5. Fetus theory, namely the development of a mechanical block due to intrauterine crowding.
  6. Neurogenic theory, the primary defect in neurogenic tissue.
  7. Amiogenic theory, that the primary defect occurs in the muscle.
  8. Edward syndrome, which is a genetic disorder of chromosome number 18.
  9. Outside influences such as the emphasis on when the baby is still in the womb because at least the amniotic fluid (oligohydramnios)
  10. Can be found along with other congenital abnormalities such as spina bifida.
  11. Ecstasy use by the mother during pregnancy.

Impaired Verbal Communication related to Acute Tonsillitis

 
Acute Tonsillitis

Tonsillitis is defined simply as the swelling of the tonsils, which are located in the throat, towards the back of the mouth.

Acute tonsillitis comes on quickly and can be caused by a variety of organisms, including viruses, group A beta-hemolytic streptococci (Strep throat)and other types of bacteria.

Acute tonsillitis is caused by both bacteria and viruses and will be accompanied by symptoms of ear pain when swallowing, bad breath, and drooling along with sore throat and fever. In this case, the surface of the tonsil may be bright red or have a grayish-white coating, while the lymph nodes in the neck may be swollen.


Signs of Acute Tonsillitis :
  1. There is hyperaemia of pillars, soft palate and uvula.
  2. Often the breath is foetid and tongue is coasted.
  3. Tonsils are red and swollen with yellowish spots of purulent material presenting at the opening of crypts (acute follicular tonsillitis) or there may be a whitish membrane on the medial surface of tonsil which can be easily wiped away with a swab (acute membranous tonsillitis). The tonsils may be enlarged and congested so much so that they almost meet in
  4. the midline along with some oedema of the uvula and soft palate (acute parenchymatous tonsillitis).
  5. The jugulodigastric lymph nodes are enlarged and tender.


Symptoms of Acute Tonsillitis:
  1. Sore throat.
  2. Fever. It may vary from 38 to 40°C and may be associated with chills and rigors. Sometimes, a child presents with an unexplained fever and it is only on examination that an acute tonsillitis is discovered.
  3. Difficulty in swallowing. The child may refuse to eat anything due to local pain.
  4. Earache. It is either referred pain from the tonsil or the result of acute otitis media which may occur as a complication.
  5. Constitutional symptoms. They are usually more marked than seen in simple pharyngitis and may include headache, general body aches, malaise and constipation. There may be abdominal pain due to mesenteric lymphadenitis simulating a clinical picture of acute appendicitis.


Nursing Care Plan for Acute Tonsillitis

Nursing Diagnosis: Impaired verbal communication related to the effects of damage to the area to talk to the brain hemispheres.

Goal:
  • Patients are able to communicate to meet their basic needs and show improvement in their communication skills.

Interventions :
  1. Do a personal communication with the patient (often but short and easy to understand).
  2. Create an atmosphere of acceptance of the changes experienced by the patient.
  3. Teach the patient to improve communication techniques.
  4. Use non-verbal communication techniques.
  5. Collaboration in the implementation of speech therapy.
  6. Observation of the patient's ability to communicate in both verbal and non-verbal.

Nursing Care Plan for Tonsillitis

Nursing Care Plan Tonsillectomy

Nursing Interventions for Acute Tonsillitis

6 Trigger Factors of Migraine Attacks

 
Cause of migraine is not known clearly, but this can lead to a primary vascular disorder that usually occurs in women, and many have a strong tendency in the family. Migraines are also caused by the occurrence of a combination of vasodilation (widening of blood vessels) and the release of a chemical substance from nerve fibers that surrounds the blood vessels. When a migraine attack, the temporal artery (the artery that runs around the temple) will be widened. The widening will cause stretching of the nerve fibers around arteries thus stimulating these nerve fibers to release chemicals. This substance will cause inflammation, pain and migraine incredible.

Various factors that can trigger a migraine attack is determined by the presence of hereditary biological defects in the central nervous system. Among others:

1. Hormonal
Hormonal fluctuations are the trigger factor. the presence of glucose increased only 14% of women had an attack during menstruation. Reduced migraine attacks during pregnancy because estrogen levels are relatively high and constant, contrary porspartum first week, 14% of patients experienced severe attack due to lower levels of extradition. Use of the contraceptive pill also causes the frequency of migraine attacks.

 2. Menopause
Migraine generally will increase the frequency and severity at the time of menopause. However, some cases improved after menopause. Hormonal therapy with low-dose estrogen can be given to treat migraine attacks after menopause.

3. Food
Variety of foods / substances can trigger a migraine attack. Common migraine triggers are alcohol based vasodilatory effect, where wine and beer are strong triggers. Foods containing tyramine, an amino acid derived from thyroxine.

4. Monosodium Glutamate
Is the most common migraine triggers, namely: headache accompanied by anxiety, dizziness, parastesia and hands, as well as abdominal pain and chest pain.

5. Environment
Environmental changes in the body which include hormonal fluctuations in the menstrual cycle and hormonal changes can lead to getting out of bed acute migraine attacks. Changes in the external environment include the weather, season, air pressure, altitude, and late meals.

6. Sensory stimuli
Flashing light, glare, bright sunlight, or the smell of perfumes, cleaning chemicals, cigarettes, sura noise and extreme temperatures.

Benefits of Early Mobilization for Postoperative Appendectomy

 
Appendicitis is an inflammation of the appendix are relatively common which can arise without apparent cause or arise after obstruction of the appendix by feces or due to twisting of the appendix or blood vessels. Appendix inflammation causes swelling and pain that can lead to gangrene due to impaired blood supply (Corwin, 2001).

Appendicitis is the most common cause of acute inflammation in the lower right quadrant of the abdominal cavity, as well as the most common causes of emergency abdominal surgery. Approximately 7% of the population will have appendicitis at the same time in their lives, men are more frequently affected than women, and adolescents are more frequent in adults. Although it can occur at any age, appendicitis occurs most often between the ages of 10 and 30 years (Smeltzer and Bare, 2002).

According to Smeltzer and Bare (2002), appendicitis treatment is indicated when the diagnosis of appendicitis has been upheld. Antibiotics and intravenous fluids are given until surgery is performed. Analgesics can be given after the diagnosis is established. Appendectomy (surgery to remove the appendix) as soon as possible to reduce the risk of perforation. Appendectomy can be performed with general or spinal anesthesia with a lower abdominal incision or with a laparoscope, which is the latest method is very effective.

Surgery is a treatment that uses all measures invasive way to unlock or show body parts to be handled. The opening part of the body is generally done by making an incision, after which the part to be handled displayed, performed remedial action that ended with the closure and suturing wounds. The next treatment will be included in the post- surgical care. Surgery or surgery can cause a variety of complaints and symptoms. Complaints and symptoms that often is painful (Sjamsuhidajat, 2002).

Surgery leads to changes in the continuity of body tissues. To maintain homeostasis, the body is a mechanism for immediate recovery of the tissue injury experience. In the recovery process is a chemical reaction occurs in the body so that the pain felt by the patient ( Fields, in Ani, 2010). In the operation process used anesthesia so that the patient does not feel pain during surgery. But after the operation is completed and the patient regained consciousness, he will feel the pain in the body that had surgery ( Wall & Jones, in Ani, 2010).

To prevent postoperative appendectomy complications in patients appendix, the patient must be done in accordance with the stages of early mobilization. Therefore, after having an appendectomy, patients are advised not to lazy to move after surgery, the patient should fast mobilization. The faster it moves, the better, but the mobilization must be performed carefully.

Early mobilization for Postoperative Appendectomy is an important aspect of the physiological function because it is essential to maintain independence (Carpenito, in Fitriyahsari, 2009). Patients feel healthier and stronger with early ambulation. With the move, the muscles of the abdomen and pelvis will be back to normal so that the stomach muscles become strong again and can relieve pain so the patient feel healthier and help gain strength and speed healing (Mochtar, in Fitriyahsari, 2009).

Pain by The International Association for the Study of Pain is a sensory and emotional experience that is not enjoyable, accompanied by tissue damage potential and actual. Pain is a condition that is more than just a single sensation caused by a particular stimulus (Potter & Perry, 2006). Pain is felt in the appendix postoperative patients can worsen the patient's condition and even cause many complications in the appendix.

The main complication of appendicitis is perforation of the appendix, which can develop into peritonitis or abscess. The incidence of perforation was 10 % to 32 %. 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, toxic appearance, and abdominal pain or tenderness of the continuous (Smeltzer and Bare, 2002).

Nursing Assessment - Physical Examination for Appendicitis

Risk for Deficient Fluid Volume - Nursing Interventions for Appendicitis

Appendicitis Pre- and Post-Operative Care Plan

 
Appendicitis Pre Operative Care:
  • Sonde installation to decompress the stomach.
  • Catheters to control urine production.
  • Rehydration.
  • Antibiotic with broad spectrum and is given intravenously.
  • Fever-reducing medicines.
  • If fever, should be reduced before anesthesia.

Appendicitis Operative Care :
  • Appendectomy
  • Appendix removed, if the appendix is perforated freely, then the abdomen was washed with physiological saline and antibiotics.
  • Appendix abscess treated with IV antibiotics, its mass may shrink, or abscess may require drainage within a few days.
  • Appendectomy done if the abscess performed elective surgery after 6 weeks to 3 months.

Appendicitis Post Operative Care:
  • Observation of vital signs.
  • Lift the stomach sonde when patients have realized that aspiration of gastric fluid can be prevented.
  • Put the patient in a semi-Fowler position.
  • Patients are said to be good when it is in 12 hours without any disturbance, during fasting.
  • When the action is bigger operation, for example the perforation, fasting continued until bowel function returned to normal.
  • Give drink from 15 ml / hour, for 4-5 hours, then raised it to 30 ml / hour. The next day give food strain, and the next day be given soft foods.
  • One day after surgery the patient is advised to sit upright in bed for 2 × 30 min.
  • On the second day the patient can stand and sit outside the room.
  • Day 7 stitches can be removed and the patient allowed to go home.

In the appendix to the state of the masses who are still active inflammatory process that is characterized by:
  • General state of the client it still looks sick, the body temperature is still high.
  • Local examination of the right lower quadrant of the abdomen are still clear signs of peritonitis.
  • Laboratory there are leukocytosis and the counts are shifting to the left.
Surgery should be performed as soon as the client is prepared, because it feared would happen appendix abscess and generalized peritonitis. Preparation and surgery should be done as well as possible given the complications of wound infection is higher than surgery in simple appendicitis without perforation.

On the state of the appendix mass with inflammatory process has subsided characterized by:
  • General condition has improved with no visible pain, body temperature is not high anymore.
  • Local inspection abdomen there are no signs of peritonitis and only clear and palpable mass with mild tenderness.
  • Laboratory leukocyte count and differential count normal.

Actions taken should be conservative with antibiotics and bed rest. Surgery if the bleeding was more difficult and more, especially when mass appendix has formed more than a week since the attacks of abdominal pain. Surgery is carried out immediately if the treatment occurs abscess with or without generalized peritonitis.

Impaired Skin Integrity related to Cellulitis Care Plan

 
Cellulitis is a skin infection that is caused by bacteria. The bacteria called Staphylococcus aureus and Group A Streptococcus are usually responsible for this kind of infection. Streptococci and Staphylococci can enter the skin to cause cellulitis infection through scrapes, cuts, wounds, blisters, insect bites and ulcers and find their way into the dermal and subcutaneous layers of the skin. Different cellulitis infections are facial cellulitis, breast cellulitis, orbital (eye) cellulitis, periorbital (eyelid) cellulitis, hand or arm cellulitis, perianal cellulitis and lower leg or foot cellulitis.

The main symptoms are skin redness or inflammation that spreads in size as the infection spreads , tight, glossy, stretched occurrence of the skin , tenderness of the area , skin injury or rash, sudden onset ,warmth over the redskin,fever .there are some other signs of infection includes chills, shaking, fatigue, warm skin, sweating, muscle aches, myalgias. Some of the additional symptoms that may be related with this disease are nausea, vomiting and hair loss at the site of infection.


Nursing Diagnosis and Interventions for Cellulitis

Impaired Skin Integrity related to changes in turgor

Goal: Demonstrate tissue regeneration.

Outcomes:
  • Lesions began to recover and the free area of the infection,
  • Clean skin,
  • Dry and surrounding area free from edema,
  • Normal temperature.

Nursing Intervention:

1. Assess the damage, size, color depth of the liquid.
R /: proper assessment of the wound and the healing process will assist in determining further action.

2. Maintain bed rest with an increase in limb and mobilization.
R /: Circulation that can smoothly accelerate the wound healing process.

3. Maintain aseptic technique.
R /: to accelerate the wound healing process.

4. Use the compress and bandage.
R /: Compress and dressing could reduce contamination from outside.

5. Monitor the temperature of the report, report your doctor if there is improvement.
R /: Early indications for infectious complications.

Clinical Manifestation and Pathophysiology of Migraine

 
Clinical Manifestation of Migraine

Migraine is a chronic condition. Most of the migraine attacks are also accompanied with another headache. Migraine headache is often described as a severe headache, throbbing and attacking head on one side. Some pain is felt in the forehead, around the eyes and behind the head so obscure symptoms with another headache. Although most of the migraine attack on one side of the head, but often also found symptoms of migraine headaches on both sides of the head. Side of the head migraines too often turns on every time attack. Be careful when the affected side of the head is always the same, another possibility is the occurrence of a brain tumor. Patients with migraine often tormented in performing daily activities, especially when the attack occurred. Other accompanying symptoms of migraine include, nausea, vomiting, diarrhea, facial pallor, cold hands feet, and the patient will be sensitive to light and sound. Due to an increased sensitivity to light and sound then migraine sufferers had to lie in a quiet and dark room. Migraine attacks usually subside within 4 to 72 hours.

Nearly 70% had a family history of migraine. Most of the women. The first attack in the migraine usually starts during adolescence and young adulthood, and then tended to decrease at the age of 5 and 6 decades. Usually there is a triggering factor. Patients generally have a perfectionist personality, rigid, and impulsive.
The clinical features of migraine is usually a throbbing headache but unilateral and bilateral or switched sides. Migraine attacks typically 2-8 times per month, once the attack duration between 4-24 hours or longer isa, moderate-severe pain intensity, accompanying symptoms, among others,: nausea, vomiting, photophobia and / or phonophobia, pale face, vertigo , tinnitus, irritable. On migraine with aura, the symptoms prodromalnya is skotomata.teikopsia (fortification spectra), photophobia (light flashes) paresthesias and visual hallucinations exhausted, feeling tired, very hungry and feeling nervous / anxious.
Headaches often appear at the wake, but it can happen at any time.


Pathophysiology of Migraine

Signs and symptoms of migraine on the result of cerebral cortical ischemia varying degrees. Typical attack starts with a scalp artery vasoconstriction and retinal blood vessels and cerebral. Extracranial and intracranial blood vessels dilated, which causes pain and discomfort. Studies suggest that arterial dilatation hyperpermeable and cause local inflammation that sterilize, which causes pain in surrounding areas and arterial dilatation. The state aims to enable existing substances in the blood vessels (histamine, serotonin, plasmokinin) who participated in cleaning the inflammatory reaction.

Migraine attacks commonly activate the sympathetic nervous going. The meaning of the sympathetic nerve is the nerve that is part of the human nervous system is responsible for controlling the body's response to stress and pain. Increased sympathetic nervous activity in the intestine causes nausea , vomiting and diarrhea. Sympathetic activity will also lead to slow gastric emptying resulting in drug delivery to the small intestine to be absorbed will also be hampered. Barriers to drug absorption that is the problem for people with migraine when administered orally administered drug. Increased sympathetic activity also decreases the flow of blood so that the skin will appear pale and cold. Increased neural activity will also lead to increased sensitivity to light and sound.

There are various theories that explain the occurrence of migraine.

Vascular theory, disruptions vasospasm causing cerebral blood vessels constrict, causing brain hypoperfusion which began in the visual cortex and spread forward. Continued deployment of frontal headache and cause phase begins.

Theory of cortical spread depression, which in the migraine threshold value decreases neuronal excitation of neurons so easily happen, then apply shortlasting depolarization wave, by potassium - liberating depression ( decreased release of potassium ) that results in a prolonged period of depressed neurons. Furthermore, there will be deployment of depression that would suppress the activity of neurons as it passes through the cerebral cortex.

Theory of neovascular (trigeminovascular), the vasodilatory effect NOS activity and NO production would stimulate the trigeminal nerve endings in blood vessels, releasing CGRP (calcitonin gene related). CGRP binds to its receptor on mast cells and will stimulate spending meningens inflammatory mediators that lead to inflammation of neurons. CGRP is also working on the cerebral arteries and the smooth muscle that will lead to increased blood flow. In addition, CGRP will work on post junctional second order neurons site that acts as the transmission of pain impulses.

5 Types of Migraine

 
Migraine is a recurrent headache is idiopathic, with pain attacks lasting 4-27 hours, usually one-sided, throbbing nature, moderate-severe pain intensity, the more intense by regular physical activity, can be accompanied by nausea, photophobia and phonophobia. Migraines can occur in children with pain more often bifrontal location.

1. Classic Migraine
Preceded by a visual aura, a scotoma, flash of light, vision fireflies or black and white stripes, or blurred vision for 10-20 minutes. Then comes the headache, throbbing, unilateral, which is more severe, lasts between 1-6 hours. Will usually subside within 6-24 hours but sometimes longer. Accompanying symptoms are often encountered are nausea, vomiting, photophobia, phonophobia, irritable and malaise.
Classic migraine attack can be divided into three phases, namely:
1). Aura phase
When migraine with aura is connected, the aura can be more than 30 minutes and can give sufficient time for the patient to determine which drugs would be used to prevent attacks in the. This period is the manifestation of the characteristics of sensory, particularly visual disturbances (glare).
Other symptoms may occur in the presence of:
  1. Pins and needles
  2. Itchy feeling on the face and hands
  3. Confusion being
  4. A little weak on the extremities
  5. Dizziness
Period aura, is associated with vasoconstriction without pain that begins with early physiologic changes characteristic of classic migraine. Cerebral blood flow studies conducted during the headache phase of migraine attacks showed that all reduced cerebral blood flow throughout the brain, with a further loss of autoregulation and CO2 responsiveness damage.
2). Headache phase
At the time of initial symptoms began to diminish, these symptoms followed by unilateral headache (two-thirds of patients) and pulsed. Severe headache and was not able to make and is often associated with photophobia, nausea, and vomiting. Duration of this state varies, with the distance of a few hours in a day or all day.
3). Recovery phase
Is the period of muscle contraction neck and scalp are associated with local muscle pain and tension. Fatigue and exhaustion are common physical cause back pain headaches. During the post-headache phase, the patient may sleep for a long time.

2. Common Migraine
Headache arise without any prior prodromal visual aura as the classic migraine and usually lasts longer.

3. Association Migraine
At this migraine, headache accompanied by transient neurological deficits, for example in oftalmoplegik migraine, hemiplegic migraine, and migraine with aphasia. Deficit neurogis This usually occurs prior to or after the headache (migraine association) or in the absence of headache (migraine dissociation).

4. Complicated Migraine
At this migraine, neurological deficit arising will settle due to cerebral infarction. Therefore, the constrictor phase should not be given so as not to aggravate the infarction.


5. Status Migraine
Is a migraine attack that lasts more than 24 hours due to sterile inflammation around the blood vessels are dilated.

Non- Pharmacological Therapies for Constipation

 
Constipation is a condition in which a person's bowel movement difficulty with normal daily pattern. At each state of constipation, causes of constipation should be correctly identified in order to determine the therapeutic approach. Causes of constipation can be as diverse as a low fiber diet or due to the consumption of drugs hypothyroidism.

Constipation is generally regarded as the usual health problems, experienced by many people, and generally they do the treatment themselves. Problems many people experience constipation problems are usually associated with a low fiber diet. Constipation is also often wrongly understood by the general public. Society generally considers that a bowel movement every day is important for health. And assume that the bowel is not routine every day will contribute to the accumulation of toxins and lead to somatic complaints varied. This misunderstanding resulted in the use of laxatives are less rational society.

To assess the condition of constipation, required an assessment of the following variables:
  1. Frequency of bowel movements. Someone would otherwise be constipated if bowel frequency magnitude less than 3 times a week in women and 5 times per week in men.
  2. The size and consistency of stools. A person with constipation requires 25% more time than usual for the number of defecation and fecal or fewer.
  3. Symptoms as the sensation of defecation incomplete.
The following are some factors or conditions can cause constipation:
  1. Diseases of the gastrointestinal tract; irritable bowel syndrome, diverticulitis, gastrointestinal disease above the anal and rectal disease, hemorrhoids, tumors, hernia, intestinal volvulus, syphilis, tuberculosis, worm infections, limphogranuloma, hirscprung's Disease
  2. Metabolic and endocrine disorders; diabetes mellitus with neuropathy, hypothyroidism, pheochromocytoma, hypercalcemia, enteric glucagon excess.
  3. Pregnancy; Emphasis intestinal motility, increased fluid absorption from the large intestine, decreased physical activity, dietary changes, lack of fluid intake, low fiber diet, the use of iron salts.
  4. Neurogenic; central nervous system disease, brain trauma, spinal injuries kordata, central nervous system tumors, cerebrovascular accident, Parkinson's disease
  5. Psychogenic; Psychogenic to ignore / postpone the urge to defecate, psychiatric disease.
  6. Use of certain drugs


Signs and Symptoms
  1. Signs and symptoms that need to be considered in knowing whether a person is constipated or not:
  2. Keep in mind the condition whether the patient complained of a lack of volume conditions stool during bowel movements, stomach feeling full, pain during bowel movements.
  3. Signs and symptoms such as hard stools, small or dry. Abdominal discomfort, pain, cramps, nausea and vomiting, headache, and fatigue.


 Non- Pharmacological Therapies for Constipation

High Fiber Diet
Nonpharmacologic therapy is first-line therapy in the treatment of constipation by making dietary modifications to increase the amount of fiber consumed. Fibers that are part of the vegetable that is not digested in the intestines will increase stool bulk, liquid stool retention, and increase stool transit in the gut. With fiber therapy is the increased frequency of bowel movements and decrease pressure on the colon and rectum.

Patients are advised to consume at least 10 grams per day of crude fiber. Fruit, vegetables and cereals are examples of food rich in fiber. Raw bran contains about 40% fiber. In addition there are also medicinal product which is the mass of fiber-forming agents such as hydrophilic colloids psylium, methylcellulose or polikarbofil which can produce effects similar to those of high-fiber foods are available in the preparation of tablets, powders or capsules.

Surgery
In some constipated patients required surgery. This is because the presence of colonic malignancy or gastrointestinal tract obstruction that required bowel resection. Besides surgery is also necessary in cases of constipation caused by pheokromositoma.

Biofeedback
Most of the patients of constipation due to pelvic floor dysfunction benefit from the electromyogram biofeedback therapy.

Nursing Care Plan for Acute Tonsillitis

 
Tonsillitis is an inflammation of the tonsils. according to the stage, tonsillitis is divided into three stages, namely:
  1. Acute tonsillitis
  2. Membranous tonsillitis
  3. Chronic tonsillitis

Acute Tonsillitis
Acute definition is an inflammation of the tonsils and sudden in onset.

Etiology
  1. Group A Beta-Hemolytic Streptococcal.
  2. Pneumococcus.
  3. Staphylococcus.
  4. Haemophilus influenzae.

Pathophysiology
  1. Inflammation of the tonsils caused by a virus.
  2. Resulted in the formation of exudate.
  3. Cellulitis tonsils and surrounding areas.
  4. Peritonsilar abscess formation.
  5. Tissue necrosis.

Symptoms
  1. Sore throat and dysphagia.
  2. Patients do not want to eat or drink.
  3. Malaise.
  4. Fever.
  5. Breath odor.
  6. Otitis media is one of the originators.

Management
  1. Bed rest.
  2. Provision of adequate fluids and light diet.
  3. Giving medications (analgesics and antibiotics).
  4. If there is no progress then the alternative actions that can be done is surgery.

Preparation operations may be undertaken
  1. Laboratory tests (hemoglobin, leukocytes, bleeding time).
  2. Give an explanation to the client, treatment and care after surgery.
  3. Fasting 6-8 hours before surgery.
  4. Give antibiotics as prophylaxis.
  5. Give premedication ½ hours before surgery.


Assessment

1. Medical history factors associated with the occurrence of tonsillitis supporters , as well as bio - psycho - socio - spiritual.

2. Circulatory
Palpitations, headache during position changes, decreased blood pressure, bradycardia, body felt cold, pale extremities appear.

3. Elimination
Changes in the pattern of elimination ( urinary incontinence ), abdominal distension, bowel sounds disappearance.

4. Activity / rest
There is a decrease in activity due to body weakness, loss of sensation or parese / plegia , tiredness, difficulty in recuperating from muscle cramps or spasms and pain. The reduced level of consciousness, decreased muscle strength, general body weakness.

5. Nutrition and fluids
Anorexia, nausea and vomiting due to increased ICP ( intracranial pressure ), impaired swallowing, and loss of sensation on the tongue.

6. Nervous system
Dizziness / syncope, headache, decreased visual field wider / blurred vision, decreased touch sensation, especially in the area of ​​the face and extremities. Comatose mental status, weakness in the extremities, muscle paralise face, aphasia, dilated pupils, decreased hearing.

7. Comfort
Tense facial expressions, headache, restlessness.

8. Breathing
Shortened breath, inability to breathe, apnea, apnea onset period in breathing patterns.

9. Security
Fluctuations of temperature in the room.

10. Psychological
Denial, disbelief, anguish, fear, anxiety.

12 Nursing Diagnosis for Mitral Stenosis

 
Nursing Care Plan for Mitral Stenosis

Mitral stenosis is a narrowing of the mitral valve in the heart. This restricts the flow of blood through the valve. Back pressure which builds up behind the narrowed valve can cause various problems and symptoms. The more severe the narrowing, the more serious the problems.

Mitral stenosis (MS) is characterized by obstruction to left ventricular inflow at the level of mitral valve due to structural abnormality of the mitral valve apparatus. The most common cause of mitral stenosis is rheumatic fever.

Symptoms can include:
  • Shortness of breath. This tends to occur on exercise at first, but occurs at rest if the stenosis becomes worse. This symptom is due to the congestion of blood and fluid in the lungs.
  • Fainting, dizziness or tiredness. If the amount of blood getting through to the ventricle is reduced, the output of blood from the left ventricle to the body is then reduced.
  • Chest pains (angina). This may develop if there is a reduced blood flow to the coronary arteries (the arteries that take blood to the heart muscle).
  • Chest infections. These are common.
  • Coughing up blood-stained sputum. This may occur due to the congestion of blood and fluid in the lungs.
If rheumatic fever is the cause then, typically, symptoms start between the ages of 20 and 50. (That is, 10-20 years after having have had an episode of rheumatic fever as a child.)


12 Nursing Diagnosis for Mitral Stenosis

1. Ineffective individual coping
related to :
  • Situational crisis;
  • Inadequate support systems;
  • Ineffective coping methods.

2. Deficient Knowledge (learning needs)
related to :
  • Lack of knowledge;
  • Misinterpretation of information;
  • Cognitive limitations;
  • Deny the diagnosis.

3. Risk for Fluid Volume Excess
related to :
  • The displacement of the pressure on the congestive pulmonary vein;
  • Decrease in perfusion organ (kidney);
  • Increased retention of sodium / water;
  • Increased hydrostatic pressure, or decreased plasma protein (absorbs liquid in the interstitial area / tissue).

4. Risk for Impaired gas exchange
related to :
  • Alveolar - capillary membrane changes (displacement of fluid into the interstitial area / alveoli).

5. Ineffective breathing pattern
related to:
decreased lung expansion.

6. Anxiety
related to:
  • Threat of loss / death;
  • Situational crisis;
  • Threats to self-concept (self-image).

7. Ineffective Tissue perfusion
related to:
  • Decrease in peripheral blood circulation;
  • Cessation of arterial-venous flow;
  • Decrease in activity.
8. Decreased cardiac output
related to:
  • Obstruction of blood flow from the left atrium into the left ventricle,
  • Presence of ventricular tachycardia,
  • Shortening of the diastolic phase.

9. Imbalanced Nutrition: less than body requirements
related to:
  • Shortness of breath.
10. Impaired Urinary Elimination
related to:
  • Decreased glomerular perfusion;
  • Decrease in cardiac output.
11. Risk for Fluid Volume Deficit
related to:
  • Decrease in cardiac output;
  • Decline in glomerular filtration.

12. Activity intolerance
related to:
  • Decreased cardiac output,
  • Congestive pulmunal.

Fluid and Electrolyte Imbalance - Nursing Care Plan for Vomiting

 
Nursing Care Plan for Vomiting - Nursing Diagnosis : Fluid and Electrolyte Imbalance : less than body requirements.

Vomiting is a symptom, not a disease. Symptoms of this form of discharge of the contents of the stomach and intestines through the mouth, with a force. Vomiting is the body's protective reflex, because it can protect against toxins accidentally ingested. In addition, an attempt vomiting removing toxins from the body and can reduce the pressure caused by the blockage or enlargement of the organ that puts pressure on the digestive tract. Generally vomiting consists of three phases, namely nausea (feeling sick), retching (initial maneuver to vomit) and regurgitation (evisceration stomach / intestine into the mouth).

Vomiting occurs through a mechanism that is very complex. The occurrence of vomiting is controlled by the vomiting center in the central nervous system (brain) us. Vomiting occurs when there are certain conditions that stimulate the vomiting center. Stimulation of the vomiting center and then proceed to the diaphragm (the partition between the chest and abdomen) and stomach muscles, resulting in decreased diaphragm and constricting (shrinking) the muscles of the stomach. That in turn resulted in increased pressure in the abdomen especially in the stomach and cause the release of stomach contents through the mouth. Some conditions that can stimulate the vomiting center in which various gastrointestinal disorders in both infections (including gastroenteritis) and non-infectious (such as obstruction of the digestive tract), toxins (poisons) in the digestive tract, balance disorders, and metabolic disorders.

Nursing Care Plan for Vomiting : Fluid and Electrolyte Imbalance : less than body requirements related to excessive fluid output.

Goal: fluid and electrolyte deficits resolved

Outcomes:
  • There are no signs of dehydration,
  • mucosa of the mouth and lips moist,
  • fluid balance.

Intervention:
  • Observation of vital signs.
  • Observation for signs of dehydration.
  • Measure the input and output of fluid (fluid balance).
  • Provide and encourage the family to drink a lot more than 2000 - 2500 cc per day.
  • Collaboration with physicians in fluid therapy, electrolyte laboratory examination.
  • Collaboration with a team of nutrition in low-sodium fluids.

Factors Influencing Health Status of The Elderly

 
There are several factors that affect the mental health of the elderly. These factors shall be addressed wisely so that the elderly can enjoy their life happily. As for some of the factors facing the elderly are greatly affecting their mental health is as follows:

1. Decrease in Physical Condition

After someone entered the elderly, generally ranging seized their physical condition, which is pathological regression (multiple pathology), for example, reduced power, decreased energy, more wrinkled skin, the more teeth fall out, the more brittle bones, etc..

In general, the physical condition of a person who has entered a period of elderly decline exponentially. This all may cause interference or physical dysfunction, psychological and social, which in turn can lead to a state of dependence on others. In the lives of the elderly in order to maintain a healthy physical condition, it is necessary to align with the physical needs psychological and social conditions, so inevitably there must be efforts to reduce the activities of a physical memforsir. An elderly should be able to set a good way of life, such as eating, sleeping, rest and work in balance.



2. Decrease Function and Sexual Potency

Decrease function and sexual potency in the elderly is often associated with a variety of physical disorders such as:
  1. Heart problems.
  2. Metabolic disorders, eg, diabetes mellitus.
  3. Vaginitis.
  4. Recently completed operations: for example prostatectomy.
  5. Malnutrition, due to imperfect digestion or appetite is very less.
  6. The use of certain medications, such as antihypertensives, steroid group, tranquilier.
  7. Psychological factors that accompany the elderly, among others:
    • Sense of taboo or embarrassment when maintaining sexual life of the elderly.
    • Attitudes families and communities that lack support and strengthened by tradition and culture.
    • Fatigue or boredom due to lack of variation in his life.
    • Spouse has died.
    • Sexual dysfunction due to hormonal changes or other mental health problems anxiety, depression, dementia, etc..

3. Changes in Psychosocial Aspects

In general, after entering the elderly then it decreased cognitive and psychomotor function. Cognitive function includes the process of learning, perception, comprehension, understanding, attention and others that cause reactions and behaviors of the elderly become increasingly slow. While psychomotor function (conative) covers matters relating to such will boost the movement, action, coordination, resulting in that the elderly become less nimble.
With the decrease in both functions, the elderly also experience changes in psychosocial aspects related to the state of kepabrikan elderly. Some of these changes can be differentiated based on 5 elderly personality types as follows:
  1. Construction personality , usually this type is not a lot experienced turmoil , calm and steady until very old .
  2. Independent personaliy , there is a tendency in this type of experience post power syndrome , especially if in the future be filled with the elderly are not activities that can provide autonomy on him .
  3. Dependent personality , in this type usually greatly affected family life , family life always harmonious if the elderly are not volatile at times , but if the spouse dies, the spouse left behind will be miserable , especially if you do not get up from his position .
  4. Hostility personality , in this type after entering the elderly are still not satisfied with his life , a lot of desire that is sometimes not in the carefully calculated , causing economic conditions to be messy .
  5. Self Hate Personality , the elderly of this type generally looks miserable , because the behavior itself is difficult aided by others or themselves tend to be difficult .

Nursing Diagnosis and Interventions of Activity Intolerance in Elderly

 
Assessment

1. Physical examination:
  • Musculoskeletal: decreased tone, strength, muscle size and endurance; range of motion of joints and skeletal strength.
  • Cardiovascular: the formation of thrombosis, thrombophlebitis signs include: erythema, edema, tenderness and signs of positive Humans.
  • Respiration: atelectasis and pneumonia symptoms, early signs include an increase in temperature and heart rate.
  • Integument: ischemia injury against the first tissue is inflammatory, early changes seen on the surface of the skin as an irregular area of erythema.
  • Urinary function: physical signs such as urinating a little and often, lower abdominal distension and bladder limits that can be touched.
  • Gastrointestinal: constipation and faecal going small, hard and dry.
  • Environment: bathroom without handles, loose rugs, lighting is not adequate, a high ladder, slippery floor and toilet seat that lowers the client mobility.

2. Assessing the skeletal body: The deformity and alignment. Abnormal bone growth due to bone tumors. Shortening of limb, amputation and body parts that are not in anatomical alignment. Abnormal angulation of the long bones or movement at a point other than the joints usually indicate the presence of fractures.

3. Assessing the spine:
  • Scoliosis (curvature of the lateral deviation of the spine)
  • Kyphosis (curvature of the spine increase the chest)
  • Lordosis (quack, the curvature of the lumbar spine over)
4. Assessing joint system: Broad movement was evaluated both active and passive, deformity, stability, and the lumps, the joint stiffness.

5. Assessing muscle system: The ability to change the position, muscle strength and coordination, and the size of each muscle. Limb circumference to mementau or atropfi edema, muscle pain.

6. Assessing how patients walk: The irregular movements are not considered normal. If one limb shorter than the other. A variety of neurological conditions associated with abnormal gait (eg walking spastic hemiparesis way - stroke, patients go step by step - lower motor neuron disease, patients walked vibrate - Parkinson's disease).

7. Assessing the skin and the peripheral circulation: palpation of the skin can indicate a temperature hotter or colder than others and the edema. Peripheral circulation was evaluated by assessing peripheral pulses, color, temperature and capillary refill time.

8 . Assessment of functional status :
  • Baths : Told independent when in client activity just need help to scrub or clean up a certain portion of the body member , said the dependent if the client requires assistance to more than one body part .
  • Dress : Independent if unable to take his own clothes in a closet or drawer .
  • To the toilet : Independent when the elderly can not afford to own a toilet , getting out of the toilet and hem itself . Dependent when it need a bed pan or pot .
  • Transferring : Independent themselves when able to climb down from a bed or wheelchair . Dependent if always require assistance for activities above or unable to perform one or more activities of transferring .
  • Continence : Independent shitting themselves when able ( urinary and defecation ) . When dependent on one or both of micturition or sefekasi require enema or catheter .
  • Eating : Independent if it is able to bribe their own food , take away from the plate .


Nursing Diagnosis and Interventions of Activity Intolerance in Elderly

Nursing Diagnosis : Impaired Physical Mobility related to depression

Goal : Depression can be resolved and activities to do.

Outcomes:

Clients can perform daily activities , and depression disappeared .

Intervention :
  1. The prevention of osteoporosis , either through medical intervention , nutrition , as well as lifestyle adjustments .
  2. The prevention of falls in accordance with the results of the assessment of the environmental factors as well as risk factors does surgery on the risk of environmental factors .
  3. Maintenance of strength and resilience of the musculoskeletal system , which includes daily exercise conditioning program both isometric and isotonic muscle contraction , strengthening and aerobic activity , nutrition and protein anabolism to increase bone formation and attitude of commitment to exercise .
  4. Maintaining the flexibility of the joints involved in range of motion exercises , proper positioning and activities of daily living .
  5. Maintenance of normal ventilation and hyperinflation include mobilization and eliminate secretions .
  6. Maintenance of adequate circulation include supporting measures to maintain vascular tone , compression stockings to put external pressure on the limbs and adequate fluid intake to prevent dehydration effect on blood volume .
  7. Maintenance of urinary and bowel function were normal relies on nutritional support and environmental structure and routines to facilitate elimination .

7 Minimum Standards of Antenatal Care

 
Antenatal Care (ANC) is a prenatal care provided by a midwife or doctor to the mother during pregnancy to optimize mental and physical health of pregnant women, so as to face childbirth, childbirth preparation, breastfeeding, and the return of normal reproductive health (Manuaba, 1998) .

Antenatal antenatal examination is done to check on the mother and fetus at regular intervals, followed by efforts to correct the deviations found (Antenatal Care Guidelines on Basic Service Level, 2004: 1).

7 Minimum Standards Antenatal Care

According to Saifuddin (2002) Antenatal care covers a lot of things, but in the application of the minimum standards of known operations consist of:

1. Measure weight
During pregnancy is between 0.3-0.5 kg per week. When gestational age was associated with weight gain during early pregnancy ± 1 kg, then the second and third trimester, respectively increases of 5 kg. At the end of pregnancy weight gain total is 9-12 kg. If there is excessive weight gain should be considered towards the risk as swelling, multiple pregnancy, hydramnios, and a great kid.

2. Measure blood pressure
During pregnancy, high blood pressure when more than 140/90 mmHg. When blood pressure increases, ie 30 mmHg systolic or more and or diastolic 15 mm Hg or more. These abnormalities may progress to preeclampsia and eclampsia if not handled properly.

3. Measure the height of fundus of uterus

Normal fundus height is as follows:
12 weeks: 1-2 fingers above the symphysis.
16 weeks: halfway between the symphysis-center.
20 weeks: 3 fingers under center.
24 weeks: tall center.
28 weeks: 3 fingers above the center.
32 weeks: mid-center - processus xiphoideus.
36 weeks: three fingers below the processus xiphoideus.
40 weeks: midway between the processus xiphoideus - center (Mochtar, 1998)

4. TT immunization
Giving TT, will lead to a protective effect when given at least twice with a minimum interval of 4 weeks. Except if the mother had previously received TT twice in the last pregnancy or at the time of the TT pretty bride was given only once.

5. Provision of iron tablets
Basically giving iron tablets initially treated with a single daily tablet as soon as possible after the nausea passes.

6. Tests for sexually transmitted diseases.
During pregnancy, mothers should be tested for sexually transmitted diseases such as HIV / AIDS, Gonorrhoe, syphilis. That is because very influential on the fetus. If found disease - sexually transmitted diseases should be addressed.

7. Counseling
Preparation refers to higher health care, need to be prepared because the maternal and infant mortality due to delay in reaching health facilities.

Headaches During Pregnancy - Prevention and Pain Management

 
Headaches experienced during the first trimester due to the rapidly changing hormone levels, resulting in increased blood volume in the body. In addition, feelings of stress which is often plagued pregnant women is also one of the triggers of these symptoms. There are several types of headaches that can occur during pregnancy. One of them is feeling like a squeezing pain on both sides of the head or the back of the neck.

Many women who experience tension headaches during pregnancy and this may become more severe during the first trimester. This type of headache is usually caused by lack of sleep and depression during pregnancy. However, the increased levels of the hormone can also be one cause.

Mothers who are pregnant should not take carelessly known cure for fear of affecting the fetus in the womb. Most of headache medications may have harmful effects or unknown impact on infant development.


Prevention

For that to know a few things that can prevent the occurrence of headaches during pregnancy :
  1. Avoiding triggers, various things are known can be a trigger like eating late, certain smells or foods consumed.
  2. Physical activity in your daily routine, such as walking every day or doing light aerobic exercise.
  3. Perform relaxation exercises, soothing activities such as yoga, deep breathing and visualization can help keep headaches.
  4. Eat small meals but more frequently, so they can keep blood sugar levels stable and prevent headaches. If you do not eat for 2-3 hours, a quick snack consumption, such as biscuits. This will immediately raise blood sugar levels.
  5. Consume enough fluids to keep the body well hydrated. Immediately drink water or juice.
  6. Maintain a regular sleep schedule, due to fatigue and lack of sleep can contribute to headaches during pregnancy, and be sure to go to bed and wake up at the same time even on weekends.
  7. Maintain good posture, due to poor posture or muscle tension can cause headaches, especially the weight gain to support the pregnancy.
  8. First of all, sit down first. This method helps reduce the pain (because blood flow to the head so much smoother), also prevents falling pregnant women.
  9. If it will change the position of the body, do it slowly. For example, if you stand up from a lying position, try to sit down, then stand slowly.

But if the inevitable headaches and attacking pregnant women , then do the following steps :
  1. Do the rest by lying in a dark room or dim , quiet atmosphere and eyes closed .
  2. Using warm compresses to the eyes , face and temples or forehead , or could also try a cold compress on the back of the neck .
  3. Ask someone to do massage on the shoulders and neck to relieve tension , or massaging the temples also can help . Actually , headache disorders are not severe .
But , if the second trimester headaches for the first time ( both with impaired vision or not , abdominal pain , skyrocketing weight gain , and swelling of the face or hands ) , soon to consult a midwife or a doctor . Could be , blood pressure and urine should be examined in the laboratory to see the possibility of developing pre - eclampsia or pregnancy poisoning . This is also the reason for the importance of antenatal care on a regular basis .

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