Nursing Care Plan for Low Self

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Nursing Care Plan for Low Self-Esteem
Low self-esteem
is a person rejects as something precious and is not responsible for their own lives. If the individualoften fails
it tends to
lower self-esteem
.
Low self-esteem
if it loses the love and appreciation of others. Self-esteemderived from self and others, the main aspect is to
be accepted and received awards from other people.
Low self-esteem disturbance
described as negative feelings about themselves, including the loss of confidence andself esteem, sense of
failure to reach the desire, self-criticism, reduced productivity, which is directed destructive toothers, feelings
of inadequacy, irritable and withdrawn socially.
Nursing Care Plan for Low Self-Esteem
Nursing Assessment for Low Self - Esteem
1.
Subjective Data: Clients say: I can not afford, can not, do not know anything, stupid, self-criticism, expressing
feelingsof shame about themselves.
2. Objective Data:Clients looked more like himself, confused when asked to choose an alternative action,
want to injure himself / wantto end life.
Nursing Diagnosis for Low Self - Esteem
1.
R
isk for Social Isolations
: withdrawing associated with low self-esteem.
2.
Self-Concept Disturbance
: low self-esteem associated with dysfunctional grieving.
Nursing Intervention for Low Self - Esteem
Goal
1.
Clients can build a trusting relationship with nurses. Action:
o
Construct a trusting relationship: Greetings therapeutic, self introduction, Explain the purpose, Create a
peacefulenvironment, definition of contract (time, place and subject.)
o
Give clients the opportunity to express his feelings.

o
Take time to listen to the client.
o
Tell the client that he is someone who is valuable and responsible and able to help themselves.2. Clients
can identify the skills and positive aspects that are owned. Action:
o
Discuss the capabilities and the positive aspects of client owned.
o
Avoid giving negative assessments of each meet clients, give praise a realistic priority.
o
Clients can assess the ability and positive aspect owned.3. Clients can assess the capabilities
that can be used. Action:
o
Discuss with the client's abilities can still be used.
o
Discuss also the ability to continue after returning home.4. Clients can define / plan activities
appropriate capabilities. Action:
o
Plan your activities with a client that can be done every day according to ability.
o
Increase activities in accordance with client's tolerance condition.
o
Give examples of how implementation of activities that clients should do.

5. Clients can perform activities according to the conditions and capabilities. Action:
o
Give a chance to try activities that have been planned.
o
Give praise for success
o
Discuss the possibility of implementation at
home.6. Clients can utilize the existing support system. Action:
o
Give health education to families about how to care for clients.
o
Helps families provide support for client care.
o

Help prepare the family environment at home.

o
Give positive reinforcement for family involvement.
Nursing diagonsis: situational low Self-Esteem related to Traumatic injury, situational crisis,forced
crisisPossibly evidenced byVerbalization of forced change in lifestyleFear of rejection or reaction by
othersFocus on past strength, function, or appearanceNegative feelings about bodyFeelings of helplessness,
hopelessness, or powerlessnessActual change in structure and functionLack of eye contactChange in
physical capacity to resume roleConfusion about self, purpose, or direction of lifeDesired
Outcomes/Evaluation CriteriaClient WillPsychosocial Adjustment: Life ChangeVerbalize acceptance of self in
situation.Recognize and incorporate changes into self-concept in accurate manner without negatingselfesteem.Develop realistic plans for adapting to role changes and new role.Nursing intervention with
rationale:1. Acknowledge difficulty in determining degree of functional incapacity and chance of functional
improvement.Rationale: During acute phase of injury, long-term effects are unknown, which delays
theclients ability to integrate situation into self-concept.2. Listen to clients comments and responses to
situation.

Rationale: Active listening provides clues to clients view of self, role changes, needs, andlevel of
acceptance.3. Assess dynamics of client and SOs, including clients role in family and cultural
factors.Rationale: Clients previous role in family unit is disrupted or altered by injury. Role changesadd
difficulty in integrating selfconcept and level of independence.4. Encourage SO to treat client as normally as
possible, such as discussing home situationsand family news.Rationale: Involving client in family unit
reduces feelings of social isolation, helplessness,and uselessness and provides opportunity for SO to
contribute to clients welfare.5. Provide accurate information. Discuss concerns about prognosis and
treatment honestlyat clients level of acceptance.Rationale: Open discussion of treatment and prognosis
may focus on current and immediateneeds. Ongoing updates enable assimilation.6. Discuss meaning of loss
or change with client and SO. Assess interactions between clientand SO.Rationale: Actual change in body
image may be different from that perceived by client.Distortions may be unconsciously reinforced by SO.7.
Accept client and show concern for individual as a person. Identify and build on clientsstrengths; give
positive reinforcement for progress noted.Rationale: Genuine concern and regard for the client as an
individual establishes therapeuticatmosphere for self-acceptance and encouragement.8. Include client and
SO in care, allowing client to make decisions and participate in self-care activities, as possible.Rationale:
Encouraging client participation in care decision making recognizes that client isstill responsible for own life
and provides some sense of control over situation. It sets thestage for future lifestyle, pattern, and interaction
required in daily care. Note: Client mayreject all help or may be completely dependent during this phase.9.
Be alert to sexually oriented jokes, flirting, or aggressive behavior. Elicit concerns, fears,and feelings about
current situation and future expectations.Rationale: Anxiety develops because of perceived loss and change
in masculine or feminineself-image and role. Forced dependency is often devastating, especially in light of
change infunction and appearance.10. Be aware of own feelings and reaction to clients sexual
anxiety.Rationale: Personal reactions to clients sexual anxiety may be as disruptive as the behavioritself,
creating conflicts between client and staff, and can potentially eliminate clientswillingness to work through
situation and participate in rehabilitation.

Brand name: Hemostan, Fibrinon, Cyklokapron, Lysteda, Transamin

Classification: Anti-fibrinolytic, antihemorrhagic
Indications:
Tranexamic acid is used for the prompt and effective control of hemorrhage in
various surgical and clinical areas:

Treating heavy menstrual bleeding

Hemorrhage following dental and/or oral surgery

in patients with hemophilia

Management of hemophilic patients (those having Factor VIII or

Factor IX deficiency) who have oral mucosal bleeding, or are
undergoing tooth extraction or other oral surgical procedures

Surgical: General surgical cases but most especially operative

procedures on the prostate, uterus, thyroid, lungs, heart, ovaries,
adrenals, kidneys, brain, tonsils, lymph nodes and soft tissues.

Obstetrical and gynecological: abortion, post-partum

hemorrhage and menometrorrahgia

Medical: epistaxis, hemoptysis, hematuria, peptic ulcer with

hemorrhage and blood dyscrasias with hemorrhage

Effective in promoting hemostasis in traumatic injuries.

Preventing hemorrhage after orthopedic surgeries.

Mechanism of Action
Tranexamic acid is a synthetic derivative of the amino acid lysine. It exerts its
antifibrinolytic effect through the reversible blockade of lysine-binding sites on
plasminogen molecules. Anti-fibrinolytic drug inhibits endometrial plasminogen
activator and thus prevents fibrinolysis and the breakdown of blood clots. The

plasminogen-plasmin enzyme system is known to cause coagulation defects

through lytic activity on fibrinogen, fibrin and other clotting factors. By
inhibiting the action of plasmin (finronolysin) the anti-fibrinolytic agents reduce
excessive breakdown of fibrin and effect physiological hemostasis.
Contraindications
1.

Allergic reaction to the drug or hypersensitivity

2.

Presence of blood clots (eg, in the leg, lung, eye, brain), have a
history of blood clots, or are at risk for blood clots

3.

Current administration of factor IX complex concentrates or

anti-inhibitor coagulant concentrates

Precautions
1.

Pregnancy. Tranexamic acid crosses the placenta.

2.

Lactation. Tranexamic acid is distributed into breast milk;

concentrations reach approximately 1% of the maternal plasma
concentration.

3.

Contraceptives, estrogen-containing, oral or Estrogens.

Concurrent use with tranexamic acid may increase
the potential for thrombus formation.

4.

Renal function impairment

(medication may accumulate;

dosage adjustment based on the degree of impairment is

recommended)
5.

Hematuria of upper urinary tract origin

(risk of intrarenal

obstruction secondary to clot retention in the renal pelvis and

ureters if hematuria is massive; also, if hematuria is associated
with a disease of the renal parenchyma, intravascular
precipitation of fibrin may occur and exacerbate the disease)
Nursing Responsibilities

1.

Unusual change in bleeding pattern should be immediately

reported to the physician.

2.

For women who are taking Tranexamic acid to control heavy

bleeding, the medication should only be taken during the
menstrual period.

3.

Tranexamic Acid should be used with extreme caution in

CHILDREN younger than 18 years old; safety and effectiveness in
these children have not been confirmed.

4.

The medication can be taken with or without meals.

5.

Swallow Tranexamic Acid whole with plenty of liquids. Do not

break, crush, or chew before swallowing.

6.

If you miss a dose of Tranexamic Acid, take it when you

remember, then take your next dose at least 6 hours later. Do
not take 2 doses at once.

7.

Inform the client that he/she should inform the physician

immediately if the following severe side effects occur:

Severe allergic reactions such as rash, hives, itching, dyspnea,

tightness in the chest, swelling of the mouth, face, lips or tongue

Calf pain, swelling or tenderness

Chest pain

Confusion

Coughing up blood

Decreased urination

Severe or persistent headache

Severe or persistent body malaise

Shortness of breath

Slurred speech

Slurred speech

Vision changes

They're the abbreviations for the 4 most common antimicrobial agents used in the treatment of active
or (to some degree) latent TB.
H = isoniazid
R = rifampin
Z = pyrazinamide
E = ethambutol