Diagnosis I:
Ineffective airway disorders associated with endotoxin reaction.
Expected results / patient evaluation criteria will be:
Showed clear breath sounds, respiratory rate within normal range, free dyspnea / cyanosis.
Intervention:
1) Maintain airway clients.
Rationale: Increased lung expansion.
2) Monitor the frequency and depth of breathing.
Rationale: Respiratory rapid / shallow due to hypoxemia, stress, and circulating endotoxin.
3) Auscultation of breath sounds.
Rational: Difficulty breathing and sound adventisius appearance is an indicator of pulmonary congestion / interstitial edema, atelectasis.
4) often change positions.
Rational: pulmonary clearance is necessary both to reduce imbalances ventelasi / perfusion.
5) Give O2 through appropriate means, eg a face mask.
Rational: O2 fix hypoxemia / acidosis. Lower respiratory humidification drying and reduce the viscosity of sputum.
Diagnosis II:
Acute pain associated with the infection process.
Expected results / patient evaluation criteria will be:
Reported pain reduced / controlled, facial expressions / body posture relaxed, participate in activities and sleep / rest appropriately.
Intervention:
1) Assess vital signs.
Rationale: Knowing the general state of the client, to determine interventions.
2) Assess characteristics of pain.
Rational: It can determine an appropriate treatment of pain and determine the cause of pain.
3) Teach distraction and relaxation techniques.
Rationale: Making clients feel comfortable and calm.
4) Maintain bed rest for the pain.
Rationale: Reduces muscle spasms.
5) Collaboration with the medical team in providing analgesic.
Rationale: Blocking the path so reduced pain and to aid wound healing.
Diagnosis III:
Hyperthermia is associated with increased metabolic rate, disease, dehydration, direct effects of circulating endotoxin in the hypothalamus, changes in temperature regulation, the infection process.
Expected results / patient evaluation criteria will be:
Demonstrating the temperature within the normal range (36 to 37.5 ° C), free from cold.
Intervention:
1) Monitor the client temperature.
Rationale: Temperature 38.9 to 41.1 oC showed acute infectious disease process.
2) Monitor intake and output and provide the preferred beverage to maintain a balance between intake and output.
Rationale: Meeting the needs of clients and help lower the fluid temperature.
3) Monitor the temperature of the environment, limit / extra bed linen as indicated.
Rational: Room temperature / number of blankets to be changed to maintain near-normal temperatures.
4) Give the bathroom a warm compress, avoid the use of alcohol.
Rational: It can help reduce the fever, because alcohol can make the skin dry.
5) Give the cooling blanket.
Rationale: Used to reduce fever.
6) Provide appropriate Antiperitik program.
Rationale: Used to reduce fever by central action on the hypothalamus.
IV Diagnosis:
Fear / anxiety associated with crisis situations, hospitalization / isolation procedure, given the experience of trauma, threat of death or disability.
Expected results / patient evaluation criteria will be:
Stating awareness of feelings and accept it in a healthy way, said the anxiety / fear decreased to levels can be handled, show problem solving skills with the effective use of resources.
Intervention:
1) Provide a description of the frequent and information about maintenance procedures.
Rationale: Knowledge of what is expected to decrease fear and anxiety, clarify misconceptions and improve cooperation.
2) Indicate the desire to hear and speak to the patient when the procedure pain free.
Rationale: Helps patient / significant other to know that support is available and that the care pembrian person interested in not only treating wounds.
3) Assess mental status, including mood / affective.
Rationale: At baseline, patients may use denial and repression to reduce and filter information overall. Some patients showed a calm and alert mental status, dissociation reality show, which is also a protection mechanism.
4) Encourage the patient to talk about injuries every day.
Rationale: Patients need to talk about what happened continuously to make some sense of the situation what is scary.
5) Explain to the patient what is happening. Give a chance to ask questions and give answers to open / honest.
Rationale: This statement shows the reality of the situation of compensation that can help the patient / significant other to accept the reality and begin to accept what happened.
Diagnosis V:
The risk of infection associated with decreased immune system, failure to resolve infection, traumatic tissue injury.
Expected results / patient evaluation criteria will be:
Achieve timely wound healing free purulent exudate and no fever.
Intervention:
1) Assess for signs of infection.
Rationale: As early diteksi infection.
2) Perform nursing aseptically and anti-septic.
Rationale: Prevent cross contamination and prevent exposure to infectious organisms.
3) Remind the client to not hold the wound and soaking the injured area.
Rationale: Prevent contamination of wounds.
4) Teach washing hands before and after contact with the client.
Rationale: Prevent cross contamination, reduce the risk of infection.
5) Check the wound daily, watch / record changes in the appearance, odor wound.
Rationale: Identifying the healing (granulation tissue) and provide early detection of wound infection.
6) Collaboration with physicians in the delivery of antibiotics.
Rationale: To avoid exposure to germs.
Ineffective airway disorders associated with endotoxin reaction.
Expected results / patient evaluation criteria will be:
Showed clear breath sounds, respiratory rate within normal range, free dyspnea / cyanosis.
Intervention:
1) Maintain airway clients.
Rationale: Increased lung expansion.
2) Monitor the frequency and depth of breathing.
Rationale: Respiratory rapid / shallow due to hypoxemia, stress, and circulating endotoxin.
3) Auscultation of breath sounds.
Rational: Difficulty breathing and sound adventisius appearance is an indicator of pulmonary congestion / interstitial edema, atelectasis.
4) often change positions.
Rational: pulmonary clearance is necessary both to reduce imbalances ventelasi / perfusion.
5) Give O2 through appropriate means, eg a face mask.
Rational: O2 fix hypoxemia / acidosis. Lower respiratory humidification drying and reduce the viscosity of sputum.
Diagnosis II:
Acute pain associated with the infection process.
Expected results / patient evaluation criteria will be:
Reported pain reduced / controlled, facial expressions / body posture relaxed, participate in activities and sleep / rest appropriately.
Intervention:
1) Assess vital signs.
Rationale: Knowing the general state of the client, to determine interventions.
2) Assess characteristics of pain.
Rational: It can determine an appropriate treatment of pain and determine the cause of pain.
3) Teach distraction and relaxation techniques.
Rationale: Making clients feel comfortable and calm.
4) Maintain bed rest for the pain.
Rationale: Reduces muscle spasms.
5) Collaboration with the medical team in providing analgesic.
Rationale: Blocking the path so reduced pain and to aid wound healing.
Diagnosis III:
Hyperthermia is associated with increased metabolic rate, disease, dehydration, direct effects of circulating endotoxin in the hypothalamus, changes in temperature regulation, the infection process.
Expected results / patient evaluation criteria will be:
Demonstrating the temperature within the normal range (36 to 37.5 ° C), free from cold.
Intervention:
1) Monitor the client temperature.
Rationale: Temperature 38.9 to 41.1 oC showed acute infectious disease process.
2) Monitor intake and output and provide the preferred beverage to maintain a balance between intake and output.
Rationale: Meeting the needs of clients and help lower the fluid temperature.
3) Monitor the temperature of the environment, limit / extra bed linen as indicated.
Rational: Room temperature / number of blankets to be changed to maintain near-normal temperatures.
4) Give the bathroom a warm compress, avoid the use of alcohol.
Rational: It can help reduce the fever, because alcohol can make the skin dry.
5) Give the cooling blanket.
Rationale: Used to reduce fever.
6) Provide appropriate Antiperitik program.
Rationale: Used to reduce fever by central action on the hypothalamus.
IV Diagnosis:
Fear / anxiety associated with crisis situations, hospitalization / isolation procedure, given the experience of trauma, threat of death or disability.
Expected results / patient evaluation criteria will be:
Stating awareness of feelings and accept it in a healthy way, said the anxiety / fear decreased to levels can be handled, show problem solving skills with the effective use of resources.
Intervention:
1) Provide a description of the frequent and information about maintenance procedures.
Rationale: Knowledge of what is expected to decrease fear and anxiety, clarify misconceptions and improve cooperation.
2) Indicate the desire to hear and speak to the patient when the procedure pain free.
Rationale: Helps patient / significant other to know that support is available and that the care pembrian person interested in not only treating wounds.
3) Assess mental status, including mood / affective.
Rationale: At baseline, patients may use denial and repression to reduce and filter information overall. Some patients showed a calm and alert mental status, dissociation reality show, which is also a protection mechanism.
4) Encourage the patient to talk about injuries every day.
Rationale: Patients need to talk about what happened continuously to make some sense of the situation what is scary.
5) Explain to the patient what is happening. Give a chance to ask questions and give answers to open / honest.
Rationale: This statement shows the reality of the situation of compensation that can help the patient / significant other to accept the reality and begin to accept what happened.
Diagnosis V:
The risk of infection associated with decreased immune system, failure to resolve infection, traumatic tissue injury.
Expected results / patient evaluation criteria will be:
Achieve timely wound healing free purulent exudate and no fever.
Intervention:
1) Assess for signs of infection.
Rationale: As early diteksi infection.
2) Perform nursing aseptically and anti-septic.
Rationale: Prevent cross contamination and prevent exposure to infectious organisms.
3) Remind the client to not hold the wound and soaking the injured area.
Rationale: Prevent contamination of wounds.
4) Teach washing hands before and after contact with the client.
Rationale: Prevent cross contamination, reduce the risk of infection.
5) Check the wound daily, watch / record changes in the appearance, odor wound.
Rationale: Identifying the healing (granulation tissue) and provide early detection of wound infection.
6) Collaboration with physicians in the delivery of antibiotics.
Rationale: To avoid exposure to germs.
