Health Care Plan

Nursing Care Plan for Pain

Pain is the most common reason a person seeking medical assistance. Pain occurs with the disease process, diagnostic examination and treatment process. Pain is very disturbing and difficult for many people. The nurse could not see and feel the pain experienced by the client, because pain is subjective (between one individual to another individual is different in addressing the pain). Nurses provide nursing care to clients in various situations and circumstances, which provide interventions to improve comfort. According to some theories of nursing, comfort is the basic requirement that the client is the goal of providing nursing care. The statement was supported by Kolcaba who said that comfort is a state has fulfilled basic human needs.

According to the International Association for the Study of Pain (IASP), pain is a subjective sensory and emotional unpleasant obtained related to actual or potential tissue damage, or described the condition of the damage.

Specificity theory “suggest” states that pain is a sensory-specific that arise because of the injury and the information is obtained through peripheral and central nervous system through the pain receptors in the peripheral nerves and specific pain in the spinal cord.
In general, nursing defines pain as anything that hurts the body of individuals who experience it who said, whenever there is an individual who said it.

Pain is tiring and requires a lot of energy
Pain is subjective and individualized
Pain can not be objectively assessed as X-rays or lab blood
Nurses can assess patients’ pain just by looking at behavioral and physiological changes of client statements
Only the client knows when the pain arises and what it’s like
Pain is a physiological defense mechanism
Pain is a warning sign of tissue damage
Pain started the inability
The false perception that pain causes pain management so it is not optimal

In summary, pain Mahon suggested the following attributes:
Pain relief is an individual
Pain is not fun
Is a strength that dominate
Are endless

Health Care Plan

Neonatal Jaundice Discharge Planning Applications

Neonatal Jaundice Discharge Planning Applications

Growth and development and the changing needs of infants with hyper-bilirubin (such as stimulation, exercise, and social contacts) has always been the responsibility of parents in fulfilling it by following the rules and the description given during hospitalization and follow-up care at home.

Factors that must be delivered to the mother can do the best in baby care hyper-bilirubinemia (warley & Wong, 1994):
1. Instruct the mother revealed / reported when the infant suffered disturbances of consciousness such as seizures, anxiety, apathy, appetite decreased breastfeeding.

2. Encourage mothers to pump milk using a tool for a few days to maintain a smooth milk.

3. Provide an explanation of procedures to lower the replacement fototherapi baby’s bilirubin levels.

4. Advised the mother to consider dismissal of the ASI in terms of preventing an increase in bilirubin.

5. Taught about skin care:

  • Bathing with mild soap and warm water.
  • Prepare the tools to clean the eyes, mouth, perineal area and the area around the damaged skin.
  • Use a moisturizer after cleansing skin to retain moisture.
  • Avoid using baby clothes on the skin adhesive.
  • Avoid the use of talc in the groin and body because it can lead to blisters due to friction
  • Looking at risk factors that can cause skin damage such as pressing a long, scratching.
  • Exempt from the skin like a wet loom: a wet diaper for the chapter and tub.
  • Conduct a rigorous assessment of the nutritional status of infants such as: skin turgor, capilari reffil.

Another thing to note is:
1. How to bathe a baby with warm water (37 -38  C)
2. Umbilical cord care / umbilicus
3. Changing diapers and baby clothes
4. Crying is a communication if the baby is uncomfortable, bored, in contact with something new
5. Temperature
6. Respiratory
7. How to breastfeed
8. Elimination
9. Circumcision care
10. Immunization
11. The signs and symptoms of disease, for example:

  • lethargy (difficult infant awakened)
  • fever (temperature over 37 celsius)
  • vomiting (most or all of the food as much as 2 x)
  • diarrhea (more than 3 x)
  • no appetite.

12. Security

  • Prevent baby from trauma such as falling sharp objects (knives, scissors) are easily accessible by the infant / toddler.
  • Prevent hot objects, electricity, and other
  • Maintain the security of the baby during the journey by car or other means.
  • Strict supervision of the infant by his brothers.
Health Care Plan

Nursing Care Plan Disturbed Sleep Pattern

Sleep Disorder

A sleep disorder, or somnipathy, is a medical disorder of the sleep patterns of a person or animal. Some sleep disorders are serious enough to interfere with normal physical, mental and emotional functioning. A test commonly ordered for some sleep disorders is the polysomnography.

Disruptions in sleep can be caused by a variety of issues, from teeth grinding (bruxism) to night terrors. When a person suffers from difficulty in sleeping with no obvious cause, it is referred to as insomnia.[1] In addition, sleep disorders may also cause sufferers to sleep excessively, a condition known as hypersomnia. Management of sleep disturbances that are secondary to mental, medical, or substance abuse disorders should focus on the underlying

Nursing Care Plan Disturbed Sleep Pattern

Nursing Care Plan Disturbed Sleep Pattern

 Disturbed Sleep Pattern

Related factors:

Associated frequent awakening:
(Damage to transport oxygen)
Respiratory disorders
Impaired circulation
(Damage to bowel and urinary elimination)
Retention of Urine
(Damage metabolism)
Gastric ulcer
Hepatic disorders
Difficulties associated with undergoing the usual position
Splints, traction
IV Therapy
Associated with excessive daytime sleep:
Situational (Personal, Environment)
Associated with excessive hyperactivity
Anxiety panic
Associated with excessive daytime sleep
Associated with ketidakadekuatan activity during the day.
Dealing with depression
Responses associated with anxiety
Associated with discomfort
Lifestyle-related disorders
Associated with changes in circadian rhythms
Dealing with fear
Dealing with fear of the dark
(Adult Women)
Associated with hormonal changes (eg, premenopausal)

Major Data :

Difficulty falling asleep and staying asleep

Minor Data :

Fatigue when awake or during the day
Or nap during the day
Changes in mood

Results Criteria

Individuals will:
1. Describe the factors that prevent or inhibit sleep.
2. Identify techniques to induce sleep.
3. reported an optimum balance of rest and activity.


1. Reduce noise.
2. Organization procedure to provide the smallest amount of disturbance during sleep periods (eg, when individuals get up to the treatment also provide handling and measurement of vital signs)
3. If urination during the night interrupt, limit your fluid intake at night and urinate before lying down.
4. Assign an individual with a schedule for program activities over time (path, physical therapy)
5. Limit the number and length of time if excessive sleep (eg, more than 1 hour)
6. Assess with individuals, families, or parents of bedtime routine – time hygiene practices, rituals (reading, toys) – and stick as close as possible whenever possible.
7. Limit drinks that contain caffeine input
8. For the children:
a. Explain to children the night (moon, stars)
b. Discuss how some people (nurses, factory workers) to work at night.
c. Compare the opposite that when night came in their place, it will happen during the day for people in other places.
d. If there is a nightmare, encourage the children to talk about it if possible. Reassure the child that this is a dream even though it seems very real. Sharing feelings with your child that you also never dreamed.
e. Give your child the night lights and / or flashlight to be used, so that children can control the darkness.
f. Reassure your child that you will be nearby sepenjang night.
9. Explain to individuals and other people closest to cause disturbance to sleep / rest and possible ways to avoid it.

Nursing Care Plan for Hyperthermia

Ineffective Breathing Pattern Care Plan

Health Care Plan

Treatment and Prevention of Hepatitis B


Hepatitis B
Key facts

  • Hepatitis B is a viral infection that attacks the liver and can cause both acute and chronic disease.
  • The virus is transmitted through contact with the blood or other body fluids of an infected person – not through casual contact.
  • About 2 billion people worldwide have been infected with the virus and about 350 million live with chronic infection. An estimated 600 000 persons die each year due to the acute or chronic consequences of hepatitis B.
  • About 25% of adults who become chronically infected during childhood later die from liver cancer or cirrhosis (scarring of the liver) caused by the chronic infection.
  • The hepatitis B virus is 50 to 100 times more infectious than HIV.
  • Hepatitis B virus is an important occupational hazard for health workers.
  • Hepatitis B is preventable with a safe and effective vaccine.

Hepatitis B is a potentially life-threatening liver infection caused by the hepatitis B virus. It is a major global health problem and the most serious type of viral hepatitis. It can cause chronic liver disease and puts people at high risk of death from cirrhosis of the liver and liver cancer.
Worldwide, an estimated two billion people have been infected with the hepatitis B virus (HBV), and more than 350 million have chronic (long-term) liver infections.
A vaccine against hepatitis B has been available since 1982. Hepatitis B vaccine is 95% effective in preventing HBV infection and its chronic consequences, and is the first vaccine against a major human cancer.


There is no specific treatment for acute hepatitis B. Care is aimed at maintaining comfort and adequate nutritional balance, including replacement of fluids that are lost from vomiting and diarrhoea.
Chronic hepatitis B can be treated with drugs, including interferon and anti-viral agents, which can help some patients. Treatment can cost thousands of dollars per year and is not available to most patients in developing countries.
Liver cancer is almost always fatal, and often develops in people at an age when they are most productive and have family responsibilities. In developing countries, most people with liver cancer die within months of diagnosis. In higher income countries, surgery and chemotherapy can prolong life for up to a few years in some patients.
Patients with cirrhosis are sometimes given liver transplants, with varying success.


All infants should receive the hepatitis B vaccine: this is the mainstay of hepatitis B prevention.
The vaccine can be given as either three or four separate doses, as part of existing routine immunization schedules. In areas where mother-to-infant spread of HBV is common, the first dose of vaccine should be given as soon as possible after birth (i.e. within 24 hours).
The complete vaccine series induces protective antibody levels in more than 95% of infants, children and young adults. After age 40, protection following the primary vaccination series drops below 90%. At 60 years old, protective antibody levels are achieved in only 65 to 75% of those vaccinated. Protection lasts at least 20 years and should be lifelong.
All children and adolescents younger than 18 years old and not previously vaccinated should receive the vaccine. People in high risk groups should also be vaccinated, including:

  • persons with high-risk sexual behaviour;
  • partners and household contacts of HBV infected persons;
  • injecting drug users;
  • persons who frequently require blood or blood products;
  • recipients of solid organ transplantation;
  • those at occupational risk of HBV infection, including health care workers; and
  • international travellers to countries with high rates of HBV.

The vaccine has an outstanding record of safety and effectiveness. Since 1982, over one billion doses of hepatitis B vaccine have been used worldwide. In many countries where 8% to 15% of children used to become chronically infected with HBV, vaccination has reduced the rate of chronic infection to less than 1% among immunized children.
As of December 2006, 164 countries vaccinate infants against hepatitis B during national immunization programmes – a major increase compared with 31 countries in 1992, the year that the World Health Assembly passed a resolution to recommend global vaccination against hepatitis B.

Health Care Plan

Nursing Care Plan: Assessment and Interventions for Self-Injury – Tentamen Suicide


Definition of a conscious and purposeful effort to end the lives of individuals is consciously desire and attempt to carry out his desire to die. Suicidal behavior include cues, trial or verbal threats, which will result in death, injury or self-injury.

Suicide as the world’s problems
The males are three times more likely to commit suicide than women, because men are more likely to use more effective tools for suicide, among others with a gun, hanging, or jumping from high buildings, while women more often use substances psychoactive drug overdose or poison, but now they are more likely to use a gun. In addition, women more often choose to save himself or others rescued.

Factors that contribute to children and adolescents

Family and immediate environment became a major pillar in charge of suicide attempts in children and adolescents, this statement is supported by Vygotsky’s theory that the child’s immediate environment contribute in shaping the character of the child’s personality, according to Stuart Sundeen personality type most often commit suicide is an aggressive type , hostility, hopelessness, low self-esteem and antisocial personality. Children will be larger when made ​​a suicide attempt came from families who apply authoritarian parenting or family who had committed suicide, emotional disturbances and their families with alcoholism.

Other psychosocial factors such as parental history of divorce, broken relationships, lost jobs or multiple stress such as moving, loss and chronic disease is accumulating a collection of stressors in the form of a less constructive coping, children will easily take a shortcut because there is no longer the place that gave him a sense of safe, according to Kaplan mental disorders and suicide in children and adolescents will emerge when environmental stressors cause increased anxiety.

Nursing Care Plan for Self-Injury – Tentamen Suicide
Nursing Assessment for Patients with Self-Injury:

Environment and suicide attempts
Nurses need to examine the events that insulting or hurtful, preparation effort, verbal expressions, records, paintings, providing valuable objects, drugs, the use of violence, poison.

The nurse noted the despair, self-reproach, feelings of failure and worthlessness, the natural feelings of depression, agitation, anxiety, insomnia persists, bewrat loss, slow speech, fatigue, withdrawal.

Psychiatric illness
Previous suicide attempts, affective disorders, addictive substances, teenage depression, elderly mental disorders.

Psychosocial history
Divorce, broken relationships, lost jobs, multiple stress (moving, loss, broken relationships, school problems, discipline crisis, chronic disease.

Personalities Factor
Impulsive, aggressive, hostile, negative cognition and kakuk, despair, low self jharga, antisocial

Family history
History of suicide, affective disorder, alcoholism

Nursing Diagnosis for Self-Injury – Tentamen Suicide

Risk for self mutilation / self-violence related to fear of rejection, the natural feeling depressed, angry reaction, the inability to express feelings verbally, the threat of self-esteem because of embarrassment, loss of jobs and so on.

Nursing Interventions for Self-Injury – Tentamen Suicide

  • Observation of client behavior more frequently through the activity, and regular interaction, avoid the impression of surveillance and suspicion on the client.
  • Establish verbal contact with the client that he would ask for help if you feel the desire to commit suicide (discuss feelings of wanting to kill herself with people you trust)
  • If self-mutilation occurs, wound care not to disturb the client with the cause, do not give positive reinforcement for these behaviors (lack of attention to maladaptive behavior can reduce repetition mutilation).
  • Encourage clients to talk about the feelings he had before this behavior to occur (in order to understand the problem)
  • Acting as a model in which the right to express anger (suicidal behavior is seen as anger directed at ourselves)
  • Remove all dangerous objects from the environment the client (the client security is a priority treatment)
  • Navigate back with the distribution of physical mutilation behavior (physical exercise is a safe way to channel the pent-up tension)
  • Commitment of all staff to give spirit to the client
  • Give medication according to the result of collaboration, monitor effectiveness, and side effects
  • Use of mechanical restrain when circumstances force according to the procedure remains
  • Observation restrain clients in every 15 minutes / according to the procedure fixed by considering the safety, blood circulation, basic needs (safety of clients is a priority nursing)
Health Care Plan

Decreased Cardiac Output – Nursing Care Plan for Angina Pectoris

Decreased Cardiac Output

NANDA Definition :

Inadequate blood pumped by the heart to meet metabolic demands of the body

Related Factors:

Myocardial infarction or ischemia, valvular disease, cardiomyopathy, serious dysrhythmia, ventricular damage, altered preload or afterload, pericarditis, sepsis, congenital heart defects , vagal stimulation, stress, anaphylaxis, cardiac tamponade

Angina Pectoris

Angina Pectoris

Angina pectoris is the result of myocardial ischemia caused by an imbalance between myocardial blood supply and oxygen demand. Angina is a common presenting symptom (typically, chest pain) among patients with coronary artery disease. A comprehensive approach to diagnosis and to medical management of angina pectoris is an integral part of the daily responsibilities of health care professionals.

NOC Outcomes (Nursing Outcomes Classification)
Suggested NOC Labels

Cardiac Pump Effectiveness
Circulatory Status
Tissue Perfusion: Abdominal Organs
Tissue Perfusion: Peripheral
Vital Signs Status

NIC Interventions (Nursing Interventions Classification)
Suggested NIC Labels

Cardiac Care: Acute
Circulatory Care

Client Outcomes

Demonstrates adequate cardiac output as evidenced by blood pressure and pulse rate and rhythm within normal parameters for client; strong peripheral pulses; and an ability to tolerate activity without symptoms of dyspnea, syncope, or chest pain
Remains free of side effects from the medications used to achieve adequate cardiac output
Explains actions and precautions to take for cardiac disease.

Nursing Intervention for Angina Pectoris

  1. Monitor vital signs, eg heart rate, blood pressure.
    Rationale: Tachycardia can occur because of pain, anxiety, hypoxemia, and decreased cardiac output. Changes also occur in blood pressure (hypertension or hypotension) due to cardiovascular response.
  2. Record the color and the presence / quality of the pulse.
    Rationale: decreased peripheral circulation when cardiac output falls, making skin color pale or gray (depending on the level of hypoxia) and decreased strength of peripheral pulses.
  3. Maintain bed rest in a comfortable position during the acute episode.
    Rationale: Lowering the oxygen consumption / demand, lowering employment and risk of myocardial decompensation.
  4. Provide supplemental oxygen as needed
    Rationale: Increase the supply of oxygen to the need to improve myocardial contractility, decrease ischemia, and lactic acid levels.
Health Care Plan

Ineffective Breathing Pattern Nursing Care Plan for Congestive Heart Failure (CHF)

Ineffective Breathing Pattern

NANDA Definition: The exchange of air inspiration and / or expiration inadequate.


  • Decrease pressure inspiration / expiration
  • Decrease in air changes per minute
  • Using additional respiratory muscle
  • Nasal flaring
  • Dyspnea
  • Orthopnea
  • Changes in chest deviation
  • Shortness of breath
  • Assumption of 3-point position
  • Breathing pursed-lip
  • Phase lasts very long expiratory
  • Increased anterior-posterior diameter
  • Respiratory average / minimum
    • Infants: less than 25 or more than 60
    • Age 1-4: less than 20 or more than 30
    • Age 5-14: less than 14 or more than 25
    • Age over 14: less than 11 or more than 24
  • Depth of respiration
    • Adult tidal volume of 500 ml at rest
    • Infant tidal volume of 6-8 ml / kg
  • Timing ratio
  • Decrease in vital capacity

Heart Failure

Ineffective Breathing Pattern  Heart Failure

Congestive heart failure is a pathophysiological state of abnormalities in cardiac function so that the heart is not able to pump blood to meet the metabolic needs of tissues and or ability to exist if accompanied by an abnormal elevation of diastolic volumes.

Predisposing factor is a disease that causes decreased ventricular function and the circumstances that limit ventricular filling. Precipitating factors including an increased intake of salt, anti-disobedient treatment of heart failure, AMI (possibly hidden), an attack of hypertension, acute arrhythmia, infection or fever, pulmonary embolism, anemia, thyrotoxicosis, pregnancy and infective endocarditis.

Nursing Diagnosis Ineffective Breathing Pattern for Congestive Heart Failure (CHF)

Goal: The pattern of breathing effectively, after the act of diving in hospital nursing, respiration normal, no additional breath sounds and the use of auxiliary respiratory muscles. And normal blood gas analysis.

Expected Outcomes:

  • Regular breathing pattern
  • Respiration returned to normal 16-24 times / minute

Nursing Interventions  Ineffective Breathing Pattern for Congestive Heart Failure (CHF)
1. Monitor respiratory depth, frequency, and chest expansion.
Rationale: Knowing the level of excess oxygen demand

2. Note the respiratory efforts include the use of auxiliary breathing muscles.
Rationale: Indicates oxygen therapy

3. Auscultation of breath sounds and note if there are additional breath sounds.
Rational: To declare the existence of pulmonary congestion or accumulation of secretions. Indicate the need for further intervention.

4. Elevate the head (position semifowler) and help to achieve a comfortable position. Collaboration of Oxygen and BGA inspection.
Rational: Meningggikan head and semi-Fowler position to reduce the burden and meringakan effort to breathe.

Health Care Plan

Acute Pain Nursing Care Plan for Peritonitis

Nursing Diagnosis for Peritonitis : Acute Pain related to inflammatory processes, fever and tissue damage.

Acute Pain NANDA Definition : Unpleasant sensory and emotional experience arising from actual or potential tissue damage or described in terms of such damage (International Association for the Study of Pain); sudden or slow onset of any intensity from mild to severe with an anticipated or predictable end and a duration of less than 6 months

Characteristics :

  • Patient reports pain
  • Guarding behavior, protecting body part
  • Self-focused
  • Narrowed focus (e.g., altered time perception, withdrawal from social or physical contact)
  • Relief or distraction behavior (e.g., moaning, crying, pacing, seeking out other people or activities, restlessness)
  • Facial mask of pain
  • Alteration in muscle tone: listlessness or flaccidness; rigidity or tension
  • Autonomic responses (e.g., diaphoresis; change in blood pressure [BP], pulse rate; pupillary dilation; change in respiratory rate; pallor; nausea)

Goal :
Pain is reduced / no pain

Expected outcomes:

  • Report: no pain / controlled
  • Demonstrate use of relaxation skills.
  • Another method to improve comfort

Nursing Interventions Acute Pain Nursing Care Plan for Peritonitis


1. Investigate reports of pain, noting location, duration, intensity (scale 0-10) and characteristics (shallow, sharp, constant)
Rationale: The change in location / intensity not common but may indicate the occurrence of complications. Pain tends to be constant, more intense, and spread upward, pain can occur if local abscess.

2. Maintain semi-Fowler’s position as indicated
Rationale: Facilitate drainage of fluids / injury, because of gravity and helps minimize the pain due to movement.

3. Provide comfort measures, sample the back massage, deep breathing, relaxation or visualization exercises.
Rationale: Increase relaxation and may enhance the patient’s coping abilities by refocusing attention.

4. Provide oral care. Eliminate unpleasant environmental stimuli.
Rational: Lowering nausea / vomiting that can increase the pressure or pain intrabdomen.


Give medications as indicated:

  • Analgesic
  • Antiemetics
  • Antipyretic

Rational: Lowering the metabolic rate and irritable bowel because of toxin circulating / local, which helps relieve pain and improve healing.

Reduces nausea / vomiting, which can increase abdominal pain

Lowering of discomfort related to fever or chills.

Health Care Plan

Mesothelioma Care Plan

Nursing Care Plan for Mesothelioma

Nursing Assessment Nursing Care Plan for Mesothelioma

Assessment is the main base of the nursing process. Assessment is the first step in one of the nursing process (Gaffar, 1999). Activities undertaken in the assessment is gathering data and formulating priority issues. In the assessment – a careful collection of data about clients, Their families, the data obtained through interviews, observation and examination.

  1. Patient Identity
    The identity of the client: name, age, sex, marital status, religion, tribe / nation, education, occupation, income, address and registration number.
  2. Main complaint: chest pain and dyspnea, hoarseness cough, anorexia, weight loss, weakness and fatigue.
  3. Previous medical history: exposure to asbestos
  4. Physical examination:
    • Inspection: shortness of breath and, finger clubbing.
    • Auscultation: diminished chest sounds
    • Percussion: dullness over lung fields

Nursing Care Plan for Mesothelioma

Nursing Diagnosis and Nursing Interventions for Mesothelioma

Source :

Health Care Plan

Pleural Effusion Care Plan

Nursing Diagnosis for Pleural Effusion

  1. Ineffective breathing pattern related to decreased lung expansion (accumulation of air / liquid), musculoskeletal disorders, pain / anxiety, the inflammatory process.
  2. Chest pain related to biologic factors (tissue trauma) and physical factors (chest tube installation)

Nursing Intervention for Pleural Effusion

  1. Ineffective breathing pattern related to decreased lung expansion (accumulation of air / liquid), musculoskeletal disorders, pain / anxiety, the inflammatory process.

    Marked by :
    Dyspnea, Tachypnoea, changes in depth of breathing, accessory muscle use, impaired development of the chest, cyanosis.

    Goal :
    The pattern of effective breath

    Expected results :

    • Indicate the normal breathing pattern / effective
    • Free cyanosis and signs of hypoxic symptoms

    Intervention :

    • Identify the etiology or trigger factor
    • Evaluation of respiratory function (rapid breathing, cyanosis, changes in vital signs)
    • Auscultation for breath sounds
    • Note the position of the chest and trachea development, review fremitus.
    • Maintain a comfortable position is usually elevated headboard
    • Give oxygen through a cannula / mask
    • If the chest tube is installed :
      • Check the vacuum controller, liquid limit
      • Observations of air bubbles bottle container
      • Hose clamps on the bottom of the drainage unit if a leak
      • Watch the ebb and flow of water reservoir
      • Note the character / amount of chest tube drainage.
  2. Chest pain related to biologic factors (tissue trauma) and physical factors (chest tube installation)

    Goal :
    Pain is reduced or lost

    Expected results :

    • The patient said the pain is reduced or can be controlled
    • Patients calm

    Intervention :

    • Assess for the presence of pain, the scale and intensity of pain
    • Teach the client about pain management and relaxation with distraction
    • Secure the chest tube to restrict movement and avoid irritation
    • Assess pain reduction measures
    • Provide analgesics as indicated

Source :