Nursing Diagnosis 1. Deficient Fluid Volume r / t excessive loss through the feces and vomit and limited intake (nausea).
Intervention and Rationale:
1. Give the oral and parenteral fluids in accordance with rehydration program.
R /: In an effort rehydration to replace fluids out with feces.
2. Monitor intake and output.
R /: Provides information about the status of the balance of fluids to determine the need for fluid replacement.
3. Assess vital signs, signs / symptoms of dehydration and laboratory results.
R /: Assessing the status of hydration, electrolyte and acid-base balance.
4. Collaboration execution of definitive therapy.
R /: Provision of drugs causally important after the cause of diarrhea in the know.
Nursing Diagnosis 2. Imbalanced Nutrition: less than body requirements r / t disruption of nutrient absorption and increase intestinal peristalsis.
Intervention and Rationale:
1. Maintain bed rest and activity restrictions during the acute phase.
R /: Lowering the metabolic needs.
2. Maintain the status of fasting, during the acute phase (according to the program of therapy) and immediately start feeding orally once conditions permit.
R /: oral dietary restrictions may be set during the acute phase to reduce peristalsis causing nutritional deficiencies. Feeding as soon as possible is important, after the client's clinical situation allows.
3. Assist with the implementation of appropriate feeding a diet program.
R /: Meeting the nutritional needs of the client.
4. Collaboration parenteral nutrition as indicated.
R /: Resting gastrointestinal work and overcome / prevent further nutritional deficiencies.
Nursing Diagnosis 3. Acute Pain r / t Hiperperistaltik, irritation perirektal fissure.
Intervention and Rationale:
1. Set a comfortable position for a client, for example with the knee flexed.
R /: Lowering the surface tension of the abdomen and reduce pain.
2. Perform the transfer of activities to provide a sense of comfort like a warm compress massage the back and abdomen.
R /: Increase relaxation, shifting the focus of attention of clients and improve coping skills.
3. Clean the anorectal area with mild soap and water after defecation and provide skin care.
R /: Protecting skin from the stool acidity, prevent irritation.
4. Collaboration of analgesic drugs and or anticholinergic indicated.
R /: Analgesics as anti-pain and anticholinergic agents to reduce spasm of the GI tract can be given appropriate clinical indications.
5. Assess pain (scale 1-10), changes in the characteristics of pain, verbal and non-verbal instructions
R /: Evaluating the development of pain to define interventions.
Nursing Diagnosis 4. Anxiety: family r / t changes in the health status of children.
Intervention and Rationale:
1. Encourage clients to discuss concerns and provide feedback on appropriate coping mechanisms.
R /: To help identify the cause of anxiety and alternative solutions to problems.
2. Emphasize that anxiety is a common problem in the elderly client whose children experienced the same problem.
R /: Help reduce stress by knowing that the client is not the only person experiencing such problems.
3. Create a quiet environment, show a friendly attitude and sincere in helping clients.
R /: Reduce external stimuli that can lead to increased anxiety.
Nursing Diagnosis 5. Knowledge deficit: family: about the condition, prognosis and therapy needs r / t exposure limited information, misinterpretation of information and or cognitive limitations.
Intervention and Rationale:
1. Assess the client's family readiness following study, including knowledge of diseases and their treatments.
R /: The effectiveness of learning is influenced by physical and mental readiness as well as background knowledge before.
2. Describe the process of their disease, its causes and consequences of the disruption of daily fulfillment of daily activities.
R /: An understanding of this issue is important to increase the participation of the client's family and the family in the treatment process client.
3. Explain the purpose of the medication, dosage, frequency and route of administration as well as possible side effects.
R /: Increase understanding client and family participation in treatment.
4. Explain and demonstrate how perineal care after defecation.
R /: Increase the independence and control the client's family to the child care needs.
