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Nursing Care Plan for Marasmic - Kwashiorkor


Assessment, Nursing Diagnosis and Interventions for Marasmic - Kwashiorkor


Assessment of Marasmic - Kwashiorkor

History of Nursing Now
In general, children admitted to hospital with complaints of impaired growth (weight progressively down), swelling in the legs, frequent diarrhea and other complaints that indicate the occurrence of malnutrition disorders.

History of Nursing Previous
Assessment includes a history of prenatal, natal and post natal, hospitalization and surgery ever experienced, allergies, behavioral patterns, growth and development, immunization, nutritional status (over, well, lacking, bad), psychosocial, psychosexual, interaction and others. Data focus that needs to be studied in this case is a history of meeting the needs of the child nutrition (protein and calorie deficiency history in a relatively long time).

Family Health History
Includes assessment of the composition of the family, home and community environment, education and employment of family members, family members functions and relations, culture and beliefs, which may affect health behaviors, perceptions of client families about the disease and others.

Physical assessment
The assessment is generally carried out by the method head to too which include: general condition and status of consciousness, vital signs, the area of ​​the head and face, chest, abdomen, extremities, and genito-urinary.

The focus of assessment in children with marasmic - Kwashiorkor is anthropometric measurements (weight, height, upper arm circles and thick folds of skin). Signs and symptoms that may be obtained are:
Decrease the size of the anthropometric
Hair changes (depigmentation, dull, dry, smooth, sparse and easily removed).
Facial features such as the elderly (lose fat cheeks), palpebral edema.
Signs of respiratory system disorders (cough, shortness, ronchi, intercostal muscle retraction).
Stomach appeared distended, palpable enlarged liver, bowel sounds can be increased if there is diarrhea.
Edema of the legs.
Dry skin, hyperpigmentation, scaly and presence crazy pavement dermatosis, especially on the part of the body that are often depressed (buttocks, popliteal fossa, knees, knuckles leg, thigh and groin).



Nursing Diagnosis for Marasmic - Kwashiorkor

  1. Imbalanced Nutrition: less than body requirements relatd to inadequate intake, anorexia and diarrhea.
  2. Fluid Volume Deficit related to a decrease in oral intake and increased loss due to diarrhea.
  3. Altered Growth and Development related to caloric and protein intake is not adequate.
  4. Risk for aspiration related to the provision of food / beverages per-sonde and increased tracheo-bronchial secretion.
  5. Ineffective airway clearance related to increased secretion of tracheo-bronchial secondary to respiratory tract infections.


Nursing Interventions for Marasmic - Kwashiorkor

1. Imbalanced Nutrition: less than body requirements relatd to inadequate intake, anorexia and diarrhea. (Carpenito, 2000, p. 645-655).


Goals :
  • The client will show an increase in nutritional status.
Outcomes:
  • Family clients can explain the cause of nutritional deficiencies experienced by the client, the needs of recovery nutrition, menu structure and processing of a healthy balanced diet.
  • With the help of the nurse, the client can demonstrate provision of family diet suitable dietetic program.

Interventions:
  • Explain to the family about the causes of malnutrition, nutritional needs recovery, menu structure and a healthy balanced food processing, show an example of the type of food sources by major socio-economic status of clients.
  • Implement the provision of appropriate treatment programs.
  • Measure weight, measure the circumference of the upper arm and the thick folds of skin every morning.

Rational:
  • Improve understanding of the family, about the causes and nutritional requirements for the client so that it can continue the recovery efforts of dietetic therapy given during hospitalization.
  • Increased appetite, absorption process and meet the deficits that accompany malnutrition.
  • Assessing the development of a client problem.

2. Fluid Volume Deficit related to a decrease in oral intake and increased loss due to diarrhea. (Carpenito, 2000, hal. 411-419).

Goal:
  • The client will show the state of adequate hydration.
Outcomes:
  • Adequate fluid intake as needed plus deficits.
  • No signs / symptoms of dehydration (vital signs within normal limits, with the consistency of defecation solid / semi-solid).

Interventions:
  • Perform / observations fluid administration by intravenous / oral rehydration programs appropriate.
  • Explain to the family of rehydration efforts and the expected participation of the family in maintaining the patency of the infusion.
  • Assess the state of development of dehydration.
  • Calculate the fluid balance.
Rational:
  • Rehydration efforts need to be done to address the problem of lack of fluid volume.
  • Increase understanding of the family and family roles rehydration efforts in the implementation of rehydration therapy.
  • Assessing the development of a client problem.
  • It is important to establish subsequent rehydration program.
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Hyperemesis Gravidarum - Assessment, Nursing Diagnosis and Interventions


Basic Concepts of Nursing

Assessment of Hyperemesis Gravidarum

a. Activity / rest
  • Decreased systolic blood pressure, increased pulse rate (> 100 beats per minute).
b. Ego integrity
  • Family interpersonal conflict, economic hardship, change perceptions about conditions, unplanned pregnancies.
c. Elimination
  • Changes in consistency; defecation, increased frequency of urination, Urinalysis: increased concentration of urine.
d. Food / fluid
  • Excessive nausea and vomiting (4-8 weeks), epigastric pain, weight loss (5-10 kg), oral mucous membrane irritation and red, low hemoglobin and hematocrit, breath smelling of acetone, reduced skin turgor, sunken eyes and dry tongue .
e. Eespiratory
  • Increased respiratory rate.
f. Security
  • Temperature sometimes rose, weakness, icterus and can fall into a coma
g. Sexuality
  • Cessation of menstruation, when the state of the mother harm done therapeutic abortion.
h. Social interaction
  • Changes in health status / stressors of pregnancy, changes in roles, family members response can vary to hospitalization and illness, lack of support system.
i. Learning and education
  • Everything is eaten and drunk vomited, especially if lasts long apalahi
  • Weight loss of more than 1/10 of the normal body berast
  • Skin turgor, dry tongue
  • The presence of acetone in the urine.
j. Diagnostic tests
  • Ultrasound (using the appropriate time): assessment of the gestational age of the fetus and the presence of multiple gestation, fetal abnormality detecting, localizing the placenta.
  • Urinalysis: culture, bacterial detection, BUN.
  • Liver function tests: AST, ALT and LDH levels.


Nursing Diagnosis for Hyperemesis Gravidarum

1. Imbalanced Nutrition, Less Than Body Requirements related to the frequency of excessive nausea and vomiting.
2. Fluid Volume Deficit related to excessive fluid loss.
3. Anxiety related to ineffective coping, physiological changes of pregnancy.
4. Activity intolerance related to weakness.


Nursing Interventions for Hyperemesis Gravidarum

1. Imbalanced Nutrition, Less Than Body Requirements related to the frequency of excessive nausea and vomiting.

Interventions:
  • Limit oral intake until the vomiting stops.
  • Give anti-emetic drugs are programmed with a low dose.
  • Maintain fluid therapy programmed.
  • Record intake and output.
  • Encourage eating in small portions but frequently.
  • Instruct to avoid fatty foods.
  • Instruct to eat a snack such as biscuit, bread and the (hot) warm before bed get up during the day and before bed.
  • Catal intake, if oral intake can not be given within a certain period.
  • Inspection Iesi irritation or mouth.
  • Assess oral hygiene and personal hygiene as well as the use of oral cleaning fluids as often as possible.
  • Monitor hemoglobin levels and Hemotokrit
  • Urine Test against acetone, albumin and glucose.
  • Measure uterine enlargement.

Rational:
  • Maintain fluid electrolyte balance and prevent further vomiting.
  • Prevent vomiting and maintaining fluid and electrolyte balance.
  • Correction presence of hypovolemia and electrolyte balance.
  • Determining hydration fluids and spending synthetically by vomiting.
  • Be sufficient intake of nutrients your body needs.
  • To stimulate nausea and vomiting.
  • Snack can reduce or avoid excessive excitatory nausea vomiting.
  • To maintain a balance of nutrients.
  • To determine the integrity inukosa mouth.
  • To maintain the integrity of the oral mucosa.
  • Identifying the presence of anemia and the potential reduction in the oxygen-carrying capacity of the mother. Clients with hemoglobin levels less than 12 g / dl or hematocrit levels less than 37% considered anemic in the first trimester.
  • Establish a baseline; done routinely to detect potential high-risk situations such as the inadequate intake of carbohydrates, Diabetic ketoacidosis and hypertension due to pregnancy.
  • Maternal malnutrition affect fetal growth and aggravate the decline in the complement of brain cells in the fetus, resulting in fetal development setbacks and further possibilities.


2. Fluid Volume Deficit related to excessive fluid loss.

Interventions :
  • Determine the frequency or severity of nausea / vomiting.
  • Review the history of the possibility of other medical problems (such as peptic ulcer, gastritis).
  • Assess body temperature and skin turgor, mucous membranes, blood pressure, input / output and urine specific gravity. Measure weight and compare it with the standard.
  • Encourage increased intake of carbonated drinks, eat as often as possible with the least amount. Foods high in carbonates such as: dry toast before getting up from bed.

Rational:
  • Provide data with respect to all conditions. Elevated levels of chorionic gonadotropin hormone (HCG), changes in carbohydrate metabolism and decreased gastric motility aggravate nausea / vomiting trimester.
  • Assist in other causes aside to address specific problems in identifying interventions.
  • As an indicator of the level or need help evaluating hydration.
  • Assist in minimizing nausea / vomiting by reducing gastric acidity.


3. Anxiety related to ineffective coping, physiological changes of pregnancy.

Interventions:
  • Control of the client environment and limit visitors.
  • Assess the client's level of psychological functioning.
  • Provide psychological support.
  • Give positive reinforcement.
  • Give maximum health.
Rational:
  • To prevent and reduce anxiety.
  • To maintain psychological integrity.
  • To reduce anxiety and foster mutual trust.
  • To alleviate the psychological effect due to pregnancy.
  • It is important for improving the mental health of the client.

4. Activity intolerance related to weakness.

Interventions:
  • Encourage clients to restrict the activities of the isrirahat enough.
  • Encourage clients to avoid heavy lifting.
  • Help clients activities gradually.
  • Encourage bed rest were modified as indicated.

Rational:
  • Save energy and avoid spending power continuously to minimize fatigue / sensitivity of the uterus.
  • Previously tolerated activity may not be modified for women at risk.
  • Activity gradually minimize trauma Seita ease in meeting their needs.
  • Periu activity levels may be modified as indicated.

Nursing Care Plan for Hyperemesis Gravidarum
READ MORE - Hyperemesis Gravidarum - Assessment, Nursing Diagnosis and Interventions

Nursing Care Plan for Hyperemesis Gravidarum

Hyperemesis Gravidarum

Nausea and vomiting is a natural phenomenon and is often caught in the first trimester of pregnancy. Nausea usually occurs in the morning, but can also occur at any time and at night. These symptoms occur approximately 6 weeks after the first day of the last menstrual period and lasts for approximately 10 weeks.

Nausea and vomiting occurred in 60% -80% primigravida, and 40% - 60% multi gravida. One in every 1000 pregnancies, these symptoms become more severe. The feeling of nausea is caused by increased levels of the hormone estrogen and HCG in serum. Physiological Effect of hormone increase is unclear, probably because the central nervous system or the reduced gastric emptying. In general, women can adjust to this situation, though the symptoms of severe nausea and vomiting that can last up to 4 months. Daily work was interrupted, and the general state of being bad. This condition is called hyperemesis gravidarum. Complaints of symptoms and physiological changes determine the severity of the disease.


Definition of Hyperemesis Gravidarum

Hyperemesis gravidarum is vomiting that occurs until 20 weeks gestation, are so great that all of what is eaten and drunk vomited thus affecting the general condition and daily work, weight loss, dehydration, there is acetone in the urine, not because of diseases such as appendicitis, pyelitis and so on.


Etiology of Hyperemesis Gravidarum

The cause of hyperemesis gravidarum is not known with certainty. Anatomic changes in the brain, heart, liver and nervous system caused by a deficiency of vitamins and other substances as a result of inanity.

Several predisposing factors and other factors were found:
  1. Predisposing factor often cited is primigravida, hydatidiform mole and multiple pregnancy. High frequency in hydatidiform mole and multiple pregnancy suggests that hormonal factors play a role, because in both circumstances chorionic gonadotropin hormone is formed in excess.
  2.  The entry of chorionic villi into the maternal circulation and metabolic changes due to pregnancy and the resistance decreases maternal tehadap this change is organic factors.
  3. Allergy. As one response from maternal tissue to fetus, also referred to as one of the organic factor.
  4. Psychological factors play an important role in this disease, although the relationship with the occurrence of hyperemesis gravidarum is not known with certainty. Households cracking, loss of job, fear of pregnancy and childbirth, fear of responsibility as a mother, can cause mental conflict that can aggravate nausea and vomiting as an unconscious expression of the reluctance to become pregnant or as an escape because of hardship. Not infrequently to give a new atmosphere has been able to help reduce the frequency of vomiting clients.


Pathophysiology of Hyperemesis Gravidarum

Some claimed that, feeling of nausea is a result of increased estrogen levels, therefore these complaints occur in the first trimester.

Psychological Influence of estrogen is not clear, perhaps derived from the central nervous system or due to reduced gastric emptying. Adjustment occurs in most pregnant women, nausea and vomiting though can take months.

Hyperemesis gravidarum is a complication of nausea and vomiting in early pregnancy, when there is persistent can lead to dehydration and electrolyte imbalance with hypochloremic alkalosis. Unclear why this phenomenon occurs only in a minority of women, but psychological factors are the main factors, in addition to hormonal factors. What is clear is that women before pregnancy is already suffering with symptoms of spastic stomach does not like to eat and nausea, emesis gravidarum will experience severe.

Hyperemesis gravidarum can lead to carbohydrate and fat reserves used up for energy purposes. Because of incomplete fat oxidation, ketosis occurs with the accumulation of acetone-acetic acid, hydroxy butyric acid and acetone in the blood. Disadvantages fluid intake and fluid loss due to vomiting cause dehydration, so the extracellular fluid and plasma is reduced. Sodium and Chloride drop in blood, urine Chloride likewise. In addition, dehydration causes hemoconcentration, so that blood flow to the tissues is reduced. This causes the amount of nutrients and oxygen to tissues and decreases the buried toxic metabolic substances. Potassium deficiency as a result of vomiting and increased excretion through the kidneys, increasing the frequency of vomiting more, can damage the liver and there was a vicious circle that is difficult to break.


Signs and Symptoms of Hyperemesis Gravidarum

Hyperemesis gravidarum, according to the severity of symptoms can be divided into three (3) levels, namely:

1. Level I:
Persistent vomiting that affects the general state of the patient, the mother feels weak, no appetite, weight loss and epigastric pain. Increased pulse about 100 times per minute, systolic blood pressure decreased, decreased skin turgor, tongue dry and sunken eyes.

2. Level II:
Patients seem more weak and apathetic, more reduced skin turgor, tongue dries and looks dirty, small and rapid pulse, temperature sometimes rises and slightly jaundice eye. Weight loss and sunken eyes, low blood pressure, hemoconcentration, oliguric and constipation.
Acetone can be smelled in the air breathing, because it has a distinctive aroma and can also be found in urine.

3. Level III:
General condition is more severe, stop vomiting, decreased consciousness and somnolence to coma, small and rapid pulse, increased body temperature and blood pressure decreases. Fatal complications can occur in the nervous system known as encephalopathy Wemicke, with symptoms: nistagtnus and diplopia. This situation is due to the very lack of nutrients, including vitamin B complex. The onset of jaundice is a sign of heart trouble.


Management of Hyperemesis Gravidarum

Prevention of Hyperemesis gravidarum should be carried out by way of the application of pregnancy and childbirth as a physiological process, providing confidence that the nausea and sometimes vomiting are symptoms that physiological early pregnancy and will disappear after 4 months of pregnancy, suggesting me to change daily meals with small amounts of food but more often. Time to wake up early do not immediately get out of bed, but it is recommended to eat dry bread or biscuits with tea.

The food is greasy and smelling of fat should be avoided. Food and drinks should be served hot or very cold.
  1. Drugs
  2. Psychological Therapy
  3. Parenteral liquid
  4. Diet
READ MORE - Nursing Care Plan for Hyperemesis Gravidarum

Nursing Diagnosis for Constipation : Acute Pain

Constipation is the inhibition of defecation (bowel movements) of a normal habit. Can be interpreted as a rare defecation, amount of stool (feces) less, or hard and dry stools. All people may experience constipation, especially in the elderly due to slower peristaltic movement and the possibility of other causes. Most occur if you eat less fiber, less drinking, and lack of exercise. This condition gets worse if it is more than three consecutive days.

Epidemiological studies show a rapid rise of constipation associated with age primarily based on patient complaints and not for clinical constipation. Many people think they are constipated if they do not defecate every day, so often there is a difference of view between physicians and patients about the meaning of constipation.

The frequency of bowel movements varies from 3 times per day to 3 times per week. In general, when 3 days have not defecation, fecal mass will harden and no trouble till pain during defecation. Constipation is often interpreted as a lack of frequency of bowel movements, usually fewer than three times per week with a small stool and hard, and sometimes with difficulty until the pain during bowel movements. Elderly people are often stuck with bowel habits.

A limitation of constipation proposed by Holson, including at least 2 of the complaint below and occurred within 3 months:

a. hard stool consistency;
b. with hard straining during bowel movements;
c. sense of incomplete bowel movements, covering 25% of the entire bowel movement;
d. defecation frequency 2 times a week or less.

Cases of constipation commonly affects approximately 4-30 percent of the general population in the age group 60 years and above. Apparently, women more often complain of constipation than men with a ratio of 3: 1 to 2: 1. The incidence of constipation increases with age, especially age 65 years and over. In a study at the age of 65 years old and over, there were people with constipation about 34 percent of women and 26 percent men.

Causes of constipation can be due to systemic factors, medication side effects, central nervous neurogenic factors, or peripheral nerves. It could also be due to abnormalities in organs such as the colon or organic obstruction of the colon muscles do not function normally or abnormalities in the rectum, pelvic floor and children and can be caused by chronic idiopathic factors.

Preventing constipation generally turns out it is not hard. Again, the key is to consume enough fiber. Fiber is most easily obtained in fruit and vegetables. If the patient is having trouble chewing constipation, for example because of a toothless, vegetables or fruit puree in a blender.



Nursing Diagnosis for Constipation : Acute Pain related to the accumulation of hard faeces in the abdomen.

Goal: show the pain has diminished.

Outcomes :
  • Shows relaxation techniques individually effective to achieve comfort.
  • Maintaining the level of pain on a small scale.
  • Reported physical and psychological health.
  • Recognizing the causes and using measures to prevent pain.
  • Using actions to reduce pain with analgesic and non-analgesic appropriately.

Nursing Interventions :

Independent
1. Help the patient to focus more on the activity of pain by doing of switching through television or radio.
R/: Clients can distract from pain.

2. Consider the possibility of drug interaction and drug disease in the elderly.
R/: Be careful in administering medications in the elderly.

Observation
3. Ask the patient to rate the pain on a scale or lack comfortable 0-10.
R/ : Knowing the client's level of perceived pain.

4. Use the pain flow sheet.
R/: Knowing the characteristics of pain.

5. Perform a comprehensive pain assessment.
R/: In order to know the specific pain.

Health education
6. Instruct the patient to the nurse if a deduction meminformasikan less pain reached.
R/: Nurses can take the appropriate action in dealing with client pain.

7. Provide knowledge about pain.
R/ : So that patients do not feel anxious.
READ MORE - Nursing Diagnosis for Constipation : Acute Pain

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