Nursing Care Plan for HNP Herniated Nucleus Pulposus wih 4 Diagnosis and Interventions

Label: Nursing Care Plan, Nursing Care Plan for HNP Herniated Nucleus Pulposus wih 4 Diagnosis and Interventions Herniated Nucleus Pulposus Intervertebral Discs are the cartilage plates that form a cushion between the vertebral bodies. Hard and fibrous material is combined in one capsule. Such as ball bearings in the middle of the disc called the nucleus pulposus. Herniated nucleus pulposus is a rupture of the nucleus pulposus. Herniated nucleus pulposus into the vertebral bodies can be above or below it, can also directly into the vertebral canal. Pain can occur in any part such as cervical spine, thoracic (rarely) or lumbar. Clinical manifestations depend on the location, speed of development (acute or chronic) and the effect on surrounding structures. Lower back pain is severe, chronic and recurring (relapse). Diagnostic Examination 1. Spinal RO: Shows the degenerative changes in the spine 2. MRI: to localize even small disc protrusion, especially for lumbar spinal disease. 3. CT Scan and Myelogram if the clinical and pathological symptoms are not visible on MRI 4. Electromyography (EMG): to localize the specific spinal nerve roots are exposed.

Assessment Nursing Care Plan for HNP Herniated Nucleus Pulposus 1. Anamnesa The main complaint, history of present treatments, medical history past, family health history. 2. Physical examination Assessment of the patient's problem consists of onset, location and spread of pain, paresthesias, limited mobility and limited function of the neck, shoulders and upperextremities. Assessment in the area include palpation of the cervical spine which aims to assessmuscle tone and rigidity. 3. Examination Support

Diagnosis Nursing Care Plan for HNP Herniated Nucleus Pulposus 1. Acute Pain 2. Impaired physical mobility 3. Anxiety 4. Knowledge deficient

Intervention Nursing Care Plan for HNP Herniated Nucleus Pulposus 1. Acute pain related to nerve compression, muscle spasm a. Assess complaints of pain, location, duration of attacks, precipitating factors / which aggravate. Set scale of 0-10 b. Maintain bed rest, semi-Fowler position to the spinal bones, hips and knees in a state of flexion, supine position

c. Use logroll (board) during a change of position d. Auxiliary mounting brace / corset e. Limit your activity during the acute phase according to the needs f. Teach relaxation techniques g. Collaboration: analgesics, traction, physiotherapy 2. Impaired physical mobility related to pain, muscle spasms, and damage neuromuskulus restrictive therapy a. Give / aids patients to perform passive range of motion exercises and active b. Assist patients in ambulation activity progressively c. Provide good skin care, massage point pressure after rehap change of position. Check the state of the skin under the brace with a specific time period. d. Note the emotional responses / behaviors in immobilizing e. Demonstrate the use of auxiliary equipment such as a cane. f. Collaboration: analgesic 3. Anxiety related to ineffective individual coping a. Assess the patient's anxiety level b. Provide accurate information c. Give the patient the opportunity to reveal problems such as the possibility of paralysis, the effect on sexual function, changes in roles and responsibilities. d. Review of secondary problems that may impede the desire to heal and may hinder the healing process. e. Involve the family 4. Knowledge deficient related to the lack of information about the condition, prognosis a. Explain the process of disease and prognosis, and restrictions on activities b. Give information about your own body mechanics to stand, lift and use the shoes backer c. Discuss about treatment and side effects. d. Suggest to use the board / mat is strong, a small pillow under your neck a little flat, bed side with knees flexed, avoid the tummy. e. Avoid the use of heaters in a long time f. Give information about the signs that need attention such as puncture pain, loss of sensation / ability to walk.

5 Nursing Diagnosis for TB Tuberculosis

Label: 5 Nursing Diagnosis for TB Tuberculosis, Nursing Diagnosis Tuberculosis is a contagious infectious disease caused by Mycobacterium tubeculosis. Tuberculosis is classified as airborne disease that is spread by droplet nuclei are expelled into the air by infected individuals in the active phase. Whenever the patient is coughing may issue a 3000 droplet nuclei. Transmission generally occurs indoors where droplet nuclei can stay in the air for much longer. Under direct sunlight tubercle bacilli die rapidly but in a dark humid chamber can last up to several hours. Two critical success factors in new individual exposure Tuberculosis ie the concentration of droplet nuclei in the air and the length of time individuals breathe in contaminated air in addition to the immune system is concerned. In addition to transmission through the respiratory tract (most frequently), M. tuberculosis can also enter the body through the digestive tract and open sores on the skin (more rarely). Tuberculosis is often dubbed "the great imitator" is a disease that has many similarities with other diseases that also gives common symptoms such as weaknessand fever. In some patients the symptoms are not clear so neglected sometimes even asymptomatic.

Clinical Manifestation of pulmonary TB can be divided into 2 groups, symptoms of respiratory and systemic symptoms: Respiratory symptoms, including: a. cough Cough symptoms occur earliest and is the disorder most often complain about. At first non productive and sputum mixed with blood even when there is tissue damage. b. coughing up blood Blood in the sputum varied issued, it may seem in the form of lines or spots of blood, blood clots or fresh blood in a number of very much. Coughing up blood due to rupture of blood vessels. Cough severity depending on the size of blood vessels to rupture. c. shortness of breath This phenomenon is found when the damage was extensive lung parenchyma or because there are things that accompany such as pleural effusion, pneumothorax, anemia and others. d. chest pain Chest pain in pulmonary TB include a mild pleuritic pain. These symptoms occur when the neural system in the pleura is affected.

5 Nursing Diagnosis for TB Tuberculosis Nursing diagnoses that commonly occurs in clients with pulmonary tuberculosis are as follows: 1. Ineffective airway clearance relate to:

thick secretions or blood secretions, weakness, bad cough effort, edema, tracheal / pharyngeal.

2. Impaired gas exchange

related to: reduced effectiveness of the surface of the lung, atelectasis, alveolar capillary membrane damage,

secretions are thick, bronchial edema.

3. Risk for Infection and spread of infection related to:

decreased immune system, decreased ciliary function, secretions are settled, tissue damage caused by the spread of infection, malnutrition, contaminated by the environment, lack of knowledge about infectious germs.

4. Imbalanced Nutrition Less Than Body Requirements related to:

fatigue, frequent coughing, production of sputum, dyspnea, anorexia, decline in financial capability.

5. Knowledge Deficit: about the condition, treatment, prevention related to:

nothing is explained, interpretation is wrong, the information is incomplete / inaccurate, limited knowledge / cognitive.