A. ASSESSMENT
• Physical Examination
• History of disease
• Assess the presence of pain, fever, weakness, weight loss, and anemia.
• Assess the future diabdomen, incontinence or urinary retention, ecchymoses on supsaorbital, exoptalmus, paralysis due to compression of the spinal nerves.
B. Nursing Diagnosis
1. The risk of injury associated with mengganasnya tumor cell proliferation, and the effects of treatment.
2. The risk of infection associated with a decrease in the body's defense system
3. The risk of lack of fluid volume associated with nausea and vomiting
4. Pain associated with doing diagnostic examinations, physiological effects neoplasms.
C. INTERVENTION
1. The risk of injury associated with mengganasnya tumor cell proliferation, and the effects of treatment.
Objective: Maintaining chemotherapeutic
Expected outcomes:> The child recovered from the disease either in part or as a whole, and the child will not suffer complications from chemotherapy
Plan
- Provide as recommended chemotherapy
- Prepare the child and the family if the surgery will be performed
- Observation signs of cystitis
- Helping children in the program radiotherapy
2. The risk of infection associated with a decrease in the body's defense system
Objective: Increase the body's defense system.
Expected outcomes:> Children will not show symptoms of infection
Plan
- Provide vaccination of inactivated viruses (eg varicella, polio Salk, influenza)
- Collaboration for drug delivery
3. The risk of lack of fluid volume associated with nausea and vomiting
Goal: Reduce nausea and vomiting.
Expected outcomes: Children will not experience nausea or vomiting.
Plan
- Collaboration for giving intravenous fluids to maintain hydration.
- Avoid giving food that has a scent that stimulates nausea or vomiting
- Encourage eating small meals but often.
4. Pain associated with doing diagnostic examinations, physiological effects neoplasms.
Goal: Reduce pain
Expected outcomes: Children will not experience pain or pain can be reduced.
Plan
- Provide techniques to reduce nonpharmacological pain.
- Assess the needs of clients to relieve pain
- Evalasi effectiveness of pain reduction therapy on a regular basis to help prevent recurrent pain.
REFERENCES
Lynda Juall C, 1999, Care Plans and Documentation Nursing, translator Esther Monica, EGC, Jakarta
Marilyn E. Doenges, 1999, Nursing care plan, Translator Kariasa I Made, EGC, Jakarta
Santosa NI, 1989, I Care (Fundamentals of Nursing), Ministry of Health of Indonesia, Jakarta.
Suharso Darto, 1994, Guidelines for the Diagnosis and Therapy, FK Airlangga University, Surabaya
