Hallucinations

Nursing Diagnosis for Hallucinations

Definition of Hallucinations

Hallucination is a false perception by the senses in the absence of external stimuli (Cook & Fontain, Essentials of Mental Health Nursing, 1987).


Classification of Hallucinations

In clients with mental disorders there are several types of hallucinations with certain characteristics, including:

1. Auditory Hallucinations: characterized by hearing the sound, especially the sound of voices, the client usually hear people talking about what he was thinking and ordered to do something.
2. Visual Hallucinations: characterized by visual stimuli in the form of radiant light, geometric picture, cartoons and / or extensive and complex panorama. Vision can be fun or scary.
3. Olfactory Hallucination: characterized by a foul odor, fishy and disgusting odors such as blood, urine or feces. Sometimes fragrant smell. Usually associated with stroke, tumors, seizures and dementia.
4. Tactile Hallucinations: characterized by pain or uncomfortable without a visible stimulus. Example: the sensation of electricity coming from the ground, inanimate objects or others.
5. Gustatory Hallucinations: characterized by feeling something rotten, putrid and disgusting.
6. General somatic sensations: characterized by feeling the body functions such as blood flow through the vein or artery, or the formation of urine ingested food.

The Process of Hallucinations

Auditory hallucinations are the most common forms of perceptual disorders in clients with mental disorders (schizophrenia). The form of hallucinations may be noises or buzzing. But the most frequent form of words arranged in sentences that influence the behavior of the client, so the client produces specific responses such as self-talk, fight or other harmful response. Can also be listening to the voice hallucinations client with attentive listening to others who do not speak or on inanimate objects.

Auditory hallucinations are a major sign of the disorder of schizophrenia and a minor diagnostic requirement for involutional melancholia, mania depressive psychosis and organic brain syndroma.


Nursing Diagnosis for Hallucination

1. Risk for Violence: Self-Directed or Other-Directed

2. Disturbed Sensory Perception: hallucination

3. Impaired Social Interaction

4. Impaired Verbal Communication

5. Altered thought processes

6. Self-care deficit

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Typoid Fever - Hyperthermia related to the infection process

Here are examples of nursing diagnosis and interventions Hyperthermia, in patients with Typoid Fever:

Nursing Diagnosis for Typoid Fever: Hyperthermia related to the infection process

Nursing Intervention:
1) Monitor the body temperature at least every 2 hours.
Rationale: Knowing the temperature changes, the temperature of 38.9 to 41.1 C showed the inflammatory process.

2) Describe efforts to address hyperthermia and assist clients / families in carrying out these efforts, such as giving a cold compress on the frontal region, groin and axilla, blanket the patient to prevent the loss of body warmth, increase your fluid intake by drinking more.
Rationale: Helps reduce fever.

3) Observation vital signs (blood pressure, temperature, pulse and respiration) every 2-3 hours.
Rationale: Vital signs can give you a general state of the client.

4) Monitor decreased level of consciousness.
Rationale: Determine interventions to prevent further complications.

6) Encourage families to limit the activities of the client.
Rationale: In order to speed up the healing process.

5) Collaboration with other medical teams to antipyretic medication and antibiotics.
Rationale: Drug antiperitik to reduce the heat and antibiotics treat infections salmonella typhi bacilli.

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Typoid Fever

Typoid fever is an acute infectious disease that usually affects the gastrointestinal tract with symptoms of more than seven days of fever, gastrointestinal disorders and disturbances of consciousness.

According to Lewis, et al (2000: 192) "Typoid fever disease caused by infection with the bacteria Salmonella typhi".

According to Ruth F Craven and Constance J, Hirnie (2002: 1011) typoid fever signs and symptoms include headache, heat, abdominal pain, diarrhea and vomiting.

According to Ngastiyah (2005: 237), Typoid fever in children are usually milder than adults. Future shoots 10-20 days, the shortest 4 days if the infection occurs through food, whereas if through drink longest 30 days. During the incubation period may be found prodromal symptoms, feeling unwell, lethargy, pain, headache, dizziness and not excited, then the following clinical symptoms that are commonly found, namely:

a. Fever
In the typical case, the fever lasts 3 weeks remitten is febrile, and the temperature was not very high. The first week, the body temperature gradually increased every day, down in the morning and rose again on the afternoon and evening. In the third week the temperature gradually dropped and normal again.

b. Disorders of the gastrointestinal tract
In the mouth there is a breath smells, lips dry and chapped. Tongue covered with dirty white membrane (coated tongue), the tip and edges red. Abdominal bloating can be found. Enlarged liver and spleen accompanied by pain and inflammation.

c. Disorders of consciousness
Generally patients decreased consciousness, namely apathy until samnolen. Rarely sopor, coma or anxiety (except for serious illness and delayed treatment). Other symptoms can also be found, in the back and limbs can be found reseol, the red spots due to emboli result in skin capillaries, which are found in the first week of fever, sometimes found also tachycardia and epistaxis.

d. Relapses
Relapse is the recurrence typoid fever symptoms, but mild and lasts shorter. Occurred in the second week after the normal body temperature, the occurrence of difficult to explain. According to the theory of relapses occur because of the presence of bacilli in organs that can not be destroyed by drugs or substances.

Nursing Diagnosis for Typoid Fever

1. Hyperthermia

2. Activity intolerance

3. Risk for fluid volume deficit

4. Imbalanced Nutrition, Less Than Body Requirements

5. Diarrhea

6. Acute Pain

7. Knowledge Deficit

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Asthma - 7 Nursing Diagnosis and Interventions

Nursing Care Plan for Asthma : Nanda Nursing Diagnosis and Interventions

1. Ineffective airway clearance related to airway spasm, secretion retention, amount of mucus.

Goal: The patient showed the ability to maintain the cleanliness of the airway, with the expected outcomes:

• There is no secret
• Lungs clear sound

Intervention:
1. Airway menagement:

• Free the airway (suction)
• Monitor the chest wall retraction
• Monitor respiration rate
• Give a semi-Fowler position

2. Clear the airway:

• Listen to lung sounds
• Encourage the patient to drink warm
• Do suction
• Monitor oxygen delivery
• Evaluation of lung sounds after suction

2. Ineffective breathing pattern related to spasm of the airway, respiratory muscle fatigue.

Goal: Adequate patient's respiratory status, with the result criteria:

• Respiration rate is within normal limits
• Not seen the use of additional respiratory muscles
• No complaints of pain in breathing

Intervention:
1. Airway management:

• Monitor respiratory patients
• Monitor the use of additional respiratory muscles (chest wall retraction)
• Monitor Vitas signs; respiration, pulse, blood pressure, temperature
• Position the patient in semi-Fowler position

2. Oxygen Therapy:

• Provide oxygen according to program
• Give oxygen through a nasal or face mask canul
  • The flow of 1-6 liters / minute oxygen concentration produces 24-44%
  • The flow of 5-8 liters / minute oxygen concentration produces 40-60%
  • The flow of 8-12 liters / min oxygen concentration produces 60-80%
  • The flow of 8-12 liters / min oxygen concentration producing 90%

3. Collaboration for bronchodilator therapy.


3.Impaired gas exchange related to bronchospasme, damage to the alveoli.

Goal: effective gas exchange, with expected outcomes:

• Free from symptoms of respiratory failure, cianosis, nostril breath
• Blood gas analysis results within normal limits.

Intervention:
1. Airway management:

• Position the patient in a position semifowler
• Auscultation of breath sounds of patients
• Patient's fluid balance
• Monitor respiration rate
• Clear the airway of secretions (Suction)
• Teach the client to use an inhaler
  

2. Acid-base management:

• Monitor blood gas analysis
• Monitor electrolyte levels
• Monitor oxygen saturation
• Collaboration of medication to maintain the acid-base balance (sodium bicarbonate)
• Monitor hemodynamic status

4. Activity intolerance related to imbalance of oxygen supplied to the needs

Goal: The patient showed tolerant state of activity, with the expected outcomes:

• No shortness of breath on exertion
• Able to move up

Intervention:
1. Energy management:

• Determine the causes of fatigue
• Monitor respiratory (respiration, dyspnoea, pallor)
• Help clients choose the activities that can be done
• Recommended to increase the intake of nutrients

2. Monitor response of breathing during activity, assess abnormal response in respiration, blood pressure, pulse.


5. Knowledge deficit: about asthma, related to lack of information sources.

Goal: increase patient knowledge about asthma, the expected outcomes:

• Knowing trigger asthma
• Knowing about the things that need to be avoided
• Knowing the handling of the attack.

Intervention:
1. Assess the things that have been known to patients

2. Assess the patient's condition before health education, do not provide health education, while patients in the state of attack.

3. Education:

• Explain the meaning of asthma
• Explain the trigger factor
• Describe the things that need to be avoided: elergan factors, stress, excessive cold weather activity
• Explain how the handler during an asthma attack at home
• Evaluate what has been delivered.

6. Anxiety related to crisis situations: changes in health status

Goal: The patient can control anxiety and increase coping, with expected outcomes:

• Patient's expression relaxed
• Vital signs are within normal limits

Intervention:
1. Lower levels of anxiety:

• Listen to their patients
• Explain each will perform maintenance procedures
• Instruct the patient to accompany the family as a support system during an asthma attack

2. Teach termination worried if stress can not be avoided:

• Turning his attention upward
• Respiratory control by drawing a deep breath (relaxation)
• Position your body relax
• Make a relaxed mood, relaxed facial expression.

7. Imbalanced Nutrition, Less Than Body Requirements related to an increase in shortness of breath, intolerance to activity

Goal: Nutrition clients adequate, with expected outcomes:

• Increased oral input

Intervention:
1. Environmental Management:

• Provide a relaxed dining atmosphere
• Limit visitors during mealtimes
  

2. Manage your nutrition:

• Assess the client's food preferences and diet recommended
• Monitor oral intake, if not enough add parenteral nutrition
• Anjurrkan eat small meals but often
• Anjurrkan for clients favorite meals
• Collaboration with the nutrition.

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Pathophysiology of Acute Gastritis and Chronic Gastritis

Pathophysiology of Acute Gastritis

Acute gastritis can be caused by stress, chemical substances such as drugs and alcohol, spicy foods, hot and sour. In experiencing the stress will occur sympathetic nerve stimulation NV (vagus nerve), which will increase the production of hydrochloric acid (HCl) in the stomach. The presence of HCl that is in the stomach will cause nausea, vomiting and anorexia.

Chemicals or stimulating foods will cause columnar epithelial cells, whose function is to produce mucus, reducing production. While it is the function of mucus to protect gastric mucosa that did not participate undigested. The response of the gastric mucosa due to decreased vasodilation, mucous secretion varies among gastric mucosal cells. There gastric mucosal lining cells produce HCl (especially the fundus) and blood vessels. Vasodilatation gastric mucosa will cause increased production of HCl. Anorexia can also cause pain. The pain inflicted by HCl contact with the gastric mucosa. Response due to decreased gastric mucosal mucus secretion may be eksfeliasi (exfoliation). Gastric mucosal cell exfoliation will lead to erosion of the mucosal cells. Mucosal cell loss due to erosion lead to bleeding. Bleeding happens to people with life-threatening, but it can also stop yourself because the process of regeneration, so that erosion disappear within 24-48 hours after hemorrhage.

Pathophysiology of Chronic Gastritis

Helicobacter pylori is a gram-negative bacteria. These organisms invade the gastric surface cells, aggravate the onset of cell desquamation and chronic inflammatory responses appeared on gastric ie: destruction of the gland and metaplasia. Metaplasia is one of the body's defense mechanism against irritation, namely by replacing the gastric mucosal cells, such as cells desquamosa stronger. Because cell desquamation stronger then the elasticity is also reduced. At the time of digesting food, the stomach peristaltic movement but as a replacement cells will give rise to inelastic stiffness, which in turn cause pain. Metaplasia also cause loss of mucous cells in the lining of the stomach, so it will cause damage to the mucosal lining of the blood vessels. Damage to blood vessels will cause bleeding (Price, Sylvia and Wilson, Lorraine, 1999: 162).

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3 Concept of Preeclampsia Prevention

According to Cuningham et al. (2005), various strategies have been used in an attempt to prevent preeclampsia. Usually, these strategies include dietary pattern and pharmacological efforts to modify the estimated pathophysiological mechanisms involved in the occurrence of preeclampsia. Pharmacologic efforts include the use of low-dose aspirin and antioxidants.

1. Diet Patterns

One of the earliest efforts aimed at preventing preeclampsia is the restriction of salt intake during pregnancy, Knuist et al. (1998)

Based largely on studies outside the United States, found that women with low calcium diet was significantly higher risk of experiencing pregnancy-induced hypertension. This encourages the execution of at least 14 randomized clinical trials that generate meta-analysis showed that calcium supplementation during pregnancy causes a significant decrease in blood pressure and prevent preeclampsia. But that seems definitive study done by Lavine et al., (1997) cited by Cuningham (2005).

This study is a randomized clinical trial sponsored by "the National Institute of Child Health and Human Development". In a test that uses a double-mimetic, the 4589 healthy nulliparous women were randomized to receive 2g calcium supplements, or placebo.

Other dietary manipulation to prevent preeclampsia that has been investigated is the provision of four to nine capsules containing fish oil every day. This daily supplement is selected as an attempt to modify the balance of the expected role of prostaglandins in the pathophysiology of preeclampsia.

2. Antioxidants

Serum of normal pregnant women has an antioxidant mechanism that serves to control lipid peroxidation is expected to play a role in endothelial cell dysfunction in preeclampsia. serum of women with preeclampsia showed a marked decrease of antioxidant activity. Schirif et al., (1996) cited by Cuningham (2005), to test the hypothesis that a decrease in antioxidant activity play a role in pre-eclampsia by studying the dietary intake and plasma concentrations of vitamin E in the 42 pregnancies in 90 controls. They found that plasma levels of vitamin E higher in women with preeclampsia, but the consumption of vitamin E in the diet is not associated with preeclampsia. They speculated that high levels of vitamin E were observed due to the response to oxidative stress in preeclampsia.

The first systematic study designed to test the hypothesis that antioxidant therapy for pregnant women would change the endothelial cell injury associated with preeclampsia. A total of 283 pregnant women 18 to 22 weeks are at risk of preeclampsia were randomized to receive antioxidant therapy or placebo. Antioxidant therapy significantly reduced endothelial cell activation and suggest that such therapy may be beneficial to prevent preeclampsia. Also significantly decreased the incidence of preeclampsia in those who received vitamin C and E compared with the control group (17 versus 11 percent, p <0.02).

3. Antenatal Care

Regular antenatal care and quality as well as meticulous, recognize early signs (mild preeclampsia), and given adequate treatment so that disease does not become more severe. Must always be alert to the possibility of preeclampsia if there are predisposing factors, providing information about the benefits of rest and sleep, calmness, and the importance to set a low salt diet, fat, and carbohydrates and high in protein, as well as maintaining excessive weight gain (Mochtar, 2007 ).

The most effective treatment is prevention. At the beginning of prenatal care, identification of high-risk pregnant women, recognition, and reporting of physical symptoms is a warning to optimize the core component of the maternal and perinatal outcomes. The ability of nurses in examining the factors and symptoms of preeclampsia on the client can not be too expected. Nurses can do many things in support tasks. Action must be taken to increase knowledge and public access to antenatal care. Counseling, delivery of public resources, the deployment system support, nutritional counseling and information about the normal adaptation to pregnancy prevention is an essential component of the treatment (Bobak, Jensen.2000).

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Gastritis

Assessment of Gastritis

During the collecting history of the disease, the nurse asked about the signs and symptoms in patients. Does the patient have heartburn, can not eat, nausea or vomiting? Do the symptoms occur at anytime, before or after meals, after ingesting spicy foods or causing irritation or after ingesting certain drugs or alcohol? What are the symptoms associated with anxiety, stress, allergies, eating or drinking too much, or eating too fast? how the symptoms disappear? Is there a history of previous gastric or stomach surgery? A history of diet plus a new type of diet eaten for 72 hours, will help. Complete history is essential in helping nurses to identify whether a known reckless excess diet, associated with current symptoms, whether others in the environment of patients had similar symptoms, whether the patient vomited blood and whether the cause of the known elements have been ingested.

Nursing Diagnosis for Gastritis

1. Anxiety
2. Imbalanced Nutrition, Less Than Body Requirements
3. Risk for Fluid Volume Deficit
4. Knowledge Deficit
5. Acute Pain

Sample of Nursing Diagnosis and Interventions for Gastritis

Nursing Diagnosis : Anxiety related to treatment

Goal : The client will show relaxed and report anxiety dropped to manageable levels.

Intervention:

Independent:
1. Assess physiological responses eg, tachypnea, palpitations, dizziness, headaches, etc..
Rational: It can be indicative of the degree of fear experienced by the patient but may also relate to the physical condition / state of shock.

2. Note the behavior of the example instructions anxiety, irritability, lack of eye contact, behavior against / attack.
Rational: Indicators of the degree of fear experienced by patients eg, patients will feel out of control of the situation or achieve status panic.

3. Encourage a statement of fear and anxiety, give feedback.
Rational: Creating a therapeutic relationship. Help the patient accept the feelings and provide an opportunity to clarify misconceptions.

4. Acknowledge that this is a scary situation and others expressed similar fear. Assist patients in expressing feelings by listening actively.
Rational: If the patient has his own fear, this feeling of validation that is normal can help patients feel less isolated.

5. Provide accurate information, real about what to do.
Rational: Involving patients in the plan of care and reduce unnecessary anxiety about the unknown.

6. Provide a quiet environment to rest.
Rationale: Increase relaxation, improve coping skills.

7. Provide opportunities for the people closest to expressing feelings / problems. Encourage the person closest to the real show positive behavior.
Rational: Helping people closest to accept the anxiety / fear itself that can be transplanted into patients. Improve the behavior of the support that can facilitate healing.

8. Show relaxation techniques, eg, deep breathing exercises, guidance imagination.
Rational: Learn how to relax can help reduce fear and anxiety.


Collaboration

1. Give the drug as an indication
Rational: Drugs that can be used occasionally to reduce anxiety and improve the rest, especially in patients with ulcers.

2. Refer to the psychiatric nurse / religious advisor
Rational: It may take an additional aid for healing to accept the consequences of emergency situations / decisions to the need / demand changes in lifestyle.

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