Research
Research nursing Marilynn E. Doenges (2000: 871-873), the basis of the study of patient data, namely:
a. Activity and Rest
Symptoms: Malaise.
b. Circulation
Tags: blood pressure normal / slightly below the normal range (for yield continues to increase cardiac output). Peripheral pulses are strong, fast, (peripheral hiperdinamik), weak / soft / easily lost, takikardi, extreme (very attractive).
c. Ego Integrity
Symptoms: Changes in health status.
Signs: strong emotional reaction, ansietas, cry, bondage, deny, withdraw.
d. Elimination
Symptoms: Diarrhea.
e. Food / fluid
Symptoms: Anorexia, nausea / vomiting.
Tags: weight loss, decrease in subcutaneous fat / muscle mass (malnutrition).
f. Neorosensori
Symptoms: Headache, dizziness, fainting.
Tags: anxious, fear, mental mess, disorientation, delirium / coma.
g. Pain / Leisure
Symptoms: abdominal cramps, pain localization, urticaria / pruritus general.
h. Breathing
Brand: Takipnea to decrease the depth of breathing.
Symptoms: umunya temperature increase (37.95 ° C or more), but probably normal, sometimes subnormal (below 36.63 ° C), chills. Wounds that are difficult / long to heal.
i. Sexuality
Symptoms: perianal pruritus, had just had a birth.
j. Integumentary
Nursing Diagnosis
- Ineffective airway disorders in relation to endotoxin reaction.
- Street Harassment is the inability of breath ineffective in cleaning secretions or obstruction of the respiratory tract to keep the airway disruption.
- Acute Pain related to chemical burns on gastric mucosa, oral cavity, physical responses, the process of infection, such as pain picture, be careful with the abdomen, stiff body posture, facial wrinkle, changes in vital signs.
- Acute Pain. Circumstances when individuals experience and report a serious uncomfortable sensation, which lasts one second until less than 6 months.
- Hipertermia relating to the sharp increase metabolism, disease, dehydration, a direct effect of endotoxin on the circulation of the hypothalamus, changes in temperature regulation, the process of infection.
- Hipertermi are occasions when individuals experiencing or at risk of increased body temperature continually higher than 37.8 ° C and 38.8 ° C orally in rectal caused by external factors.
- Fear / ansietas relating to crisis situations, treatment in hospital / isolation procedure, given the traumatic experience, the threat of death or disability.
- Fear / ansietas is a condition where an individual / group experienced a sense of physiological disorder / emotional connection with a resource that can be identified which is perceived as a danger.
- The risk of infection related to immune system decline, failure to overcome the infection, traumatic tissue injury.
- Risk is the risk of infection by organisms terinvasi pathogen.
Research nursing Marilynn E. Doenges (2000: 871-873), the basis of the study of patient data, namely:
a. Activity and Rest
Symptoms: Malaise.
b. Circulation
Tags: blood pressure normal / slightly below the normal range (for yield continues to increase cardiac output). Peripheral pulses are strong, fast, (peripheral hiperdinamik), weak / soft / easily lost, takikardi, extreme (very attractive).
c. Ego Integrity
Symptoms: Changes in health status.
Signs: strong emotional reaction, ansietas, cry, bondage, deny, withdraw.
d. Elimination
Symptoms: Diarrhea.
e. Food / fluid
Symptoms: Anorexia, nausea / vomiting.
Tags: weight loss, decrease in subcutaneous fat / muscle mass (malnutrition).
f. Neorosensori
Symptoms: Headache, dizziness, fainting.
Tags: anxious, fear, mental mess, disorientation, delirium / coma.
g. Pain / Leisure
Symptoms: abdominal cramps, pain localization, urticaria / pruritus general.
h. Breathing
Brand: Takipnea to decrease the depth of breathing.
Symptoms: umunya temperature increase (37.95 ° C or more), but probably normal, sometimes subnormal (below 36.63 ° C), chills. Wounds that are difficult / long to heal.
i. Sexuality
Symptoms: perianal pruritus, had just had a birth.
j. Integumentary
Nursing Diagnosis
- Ineffective airway disorders in relation to endotoxin reaction.
- Street Harassment is the inability of breath ineffective in cleaning secretions or obstruction of the respiratory tract to keep the airway disruption.
- Acute Pain related to chemical burns on gastric mucosa, oral cavity, physical responses, the process of infection, such as pain picture, be careful with the abdomen, stiff body posture, facial wrinkle, changes in vital signs.
- Acute Pain. Circumstances when individuals experience and report a serious uncomfortable sensation, which lasts one second until less than 6 months.
- Hipertermia relating to the sharp increase metabolism, disease, dehydration, a direct effect of endotoxin on the circulation of the hypothalamus, changes in temperature regulation, the process of infection.
- Hipertermi are occasions when individuals experiencing or at risk of increased body temperature continually higher than 37.8 ° C and 38.8 ° C orally in rectal caused by external factors.
- Fear / ansietas relating to crisis situations, treatment in hospital / isolation procedure, given the traumatic experience, the threat of death or disability.
- Fear / ansietas is a condition where an individual / group experienced a sense of physiological disorder / emotional connection with a resource that can be identified which is perceived as a danger.
- The risk of infection related to immune system decline, failure to overcome the infection, traumatic tissue injury.
- Risk is the risk of infection by organisms terinvasi pathogen.
