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)

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.

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.


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.


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

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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

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Causes of Pleural Effusion

Nursing Care Plan for Pleural Effusion

Pleural Effusion

A pleural effusion is an excess accumulation of fluid in the pleural space around the lungs. Medical ImageThe pleura are thin membranes that enclose the lungs and line the inside of the chest cavity. The ‘pleural space’ describes the small space between the inner and outer layers of pleura, which normally contains a small volume of lubricating pleural fluid to allow the lungs to expand without friction. This fluid is constantly being formed through leakage of fluid from nearby capillaries and then re-absorbed by the body’s lymphatic system. With a pleural effusion, some imbalance between production and reabsorption of pleural fluid leads to excess fluid building up in the pleural space. There are two major types of pleural effusion :

  • Transudative effusions, where the excess pleural fluid is low in protein; and
  • Exudative effusions, where the excess pleural fluid is high in protein.


Anything that causes an imbalance between production and reabsorption of pleural fluid can lead to development of a pleural effusion. Medical Image Transudative pleural effusions (those low in protein) usually form as a result of excess capillary fluid leakage into the pleural space. Common causes of transudative effusions include :

  • Congestive heart failure;
  • Nephrotic syndrome;
  • Cirrhosis of the liver;
  • Pulmonary embolism; and
  • Hypothyroidism.

Exudative effusions, which are high in protein, are often more serious than transudative effusions. They are formed as a result of inflammation of the pleura, which might happen for example in lung disease. Common causes of exudative effusions include :

  • Pneumonia;
  • Lung cancer, or other cancers;
  • Connective tissue diseases, including rheumatoid arthritis and systemic lupus erythematosus;
  • Pulmonary embolism;
  • Asbestosis;
  • Tuberculosis; and
  • Radiotherapy.

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