Nursing Diagnosis I : Body temperature imbalance: Hyperthermia related to the release of an exotoxin.
Goal: The client shows the body temperature within normal limits.
Outcomes:
- Normal temperature (36.5 to 37.2 C)
- Sweat out naturally.
1. Maintain room temperature.
R /: Can an exchange by convection temperature.
2. Give thin clothes that easily absorbs sweat.
R /: Helping the process of evaporation.
3. Give drink that much.
R /: Drinking a lot helps the drop in body temperature.
4. Collaborate with physicians for the provision of anti-pyretic.
R /: Reduce the heat in the center of the hypothalamus.
Nursing Diagnosis II : Imbalanced Nutrition: Less than Body Requirements related to pain swallow.
Goal:
- Clients can demonstrate and maintain a normal weight.
- Nutritional needs are met.
Outcomes:
- The existence of interest and appetite.
- Portions as needed.
- Increased weight.
Intervention:
1. Monitor calorie intake and quality of food consumption.
R /: Knowing food intake.
2. Monitor signs of paralysis of the soft palate and durum.
R /: food in small portions easily consumed by the client and avoid the occurrence of anorexia.
3. Give foods that stimulate appetite.
R /: Increase food intake
4. Measure body weight each day.
R /: Monitoring the effectiveness of weight and lack of nutrition are given.
Nursing Diagnosis III : Impaired gas exchange related to pseudomembranous
Goal : Maintaining the effectiveness of breathing.
Outcomes:
- No sound extra breath.
- No respirator muscle pull.
- There is no cough.
- No secretion of excessive respiratory tract.
- Respiratory frequency within normal limits.
1. Auscultation of breath sounds, note the presence of an additional breath sounds.
R/ : The presence of airway obstruction in the airways manifested.
2. Help the patient in a comfortable position, the head higher than the feet.
R/ : lower diaphragm can improve chest expansion.
3. Increase fluid intake as needed.
R/ : Thurasi helps reduce viscosity and facilitate secret spending.
4. Help perform chest physiotherapy.
R/ : Postural drainare and percussion is an important cleansing action to remove the secret and improve ventilation.
5. Perform suction.
R/ : When cleaning mechanism or airway suctioning done coughing ineffective.
6. Give oxygen as indicated.
R/ : Maximizing transport in tissue.