Nursing Care Plan

Fatigue

Fatigue is a condition with signs of reduced capacity of a person, for work and reduced efficiency of accomplishment, and this is usually accompanied by a feeling tired and weak. Fatigue can be acute and come on suddenly or chronic and persist. According to other sources of fatigue is a condition of the human body naturally feel tired, which usually happens after physical exercise or mental harm. Fatigue can be acute and come on suddenly or chronic and persist.

Usually after a long exercise, surely people will feel tired, because of all the moving limbs, limbs will be ill and do not want to continue the exercise. However, this fatigue will soon be replaced with good health and well-being. Just like a mix between fatigue and the sense of satisfaction that people feel after working hard in the office or study, this is a healthy and natural fatigue.

Fatigue at the beginning and at the end of pregnancy is also a natural thing, the reason is the increase in the activity of the hormone to be one of the causes as well as fatigue when weight babies in the womb which also makes people pregnant. Tired also can arise from psychological reasons and can be a symptom of certain diseases. But rarely the only symptom of the disease. In undetected diabetes, high levels of sugar than usual and this condition can lead to fatigue. Uncontrolled diabetes can also lead to increased levels of blood sugar and fatigue. In severe anemia, generally dilute blood, heart and lungs should strive to supply oxygen and deliver it to all the rest of the body. Fast heart rate in severe anemia may be accompanied by fatigue, anxiety, fainting, pale biscuits, and shortness of breath.

Nursing Diagnosis for Dehydration

1. Fluid volume deficit related to excessive output, less intake.
2. Risk for ineffective tissue perfusion related to decreased blood flow.
3. Risk for impaired skin integrity related to decreased skin turgor.
4. Activity intolerance related to physical weakness.
5. Risk for Decreased cardiac output related to a decrease in systemic vascular resistance.

Nursing Care Plan for Dehydration

Nursing Interventions for Dehydration

1. Fluid volume deficit related to excessive output, less intake.

Goal: adequate fluid volume so that fluid volume deficiency can be overcome.

Expected outcomes:

• Maintain fluid balance.
• Vital signs (pulse = 80-100 beats / min, temperature = 36-37oC)
• Capillary refill less than 3 seconds.
• Akral warm.
• Urine output: 1-2 cc / kg body weight / hour.

Intervention:

• Monitor vital signs, capillary refill, the status of the mucous membranes.
• Discuss strategies to stop vomiting and use of laxatives / diuretics.
• Identification of a plan to increase the optimal fluid balance.
• Assess the results of the test function electrolyte / kidney.
• Give / supervise administration of IV fluids.
• Additional potassium, oral or N as indicated.

2. Risk for ineffective tissue perfusion related to decreased blood flow.

Goal: Maintain / improve tissue perfusion.

Expected outcomes:

• Vital signs are stable BP = 120/80 mmHg, pulse = 80-100 beats / min, no pale skin.
• Warm skin.
• Palpable peripheral pulses.
• Adequate urine output from 0.5 to 1.5 cc / kg / body weight.
• CRT is less than 2 seconds.
• Composmentis consciousness.
• No chest pain.

Intervention:

• Assess changes in the level of consciousness, dizziness complaints.
• Auscultation apical pulse, watch heart rate / rhythm.
• Assess the skin against the cold, pale, sweating.
• Record output and urine specific gravity.
• Observation pale skin, redness, change positions frequently.
• Keep an eye on pulse oximetry.
• Give IV fluids as indicated.

3. Risk for impaired skin integrity related to decreased skin turgor.

Goal: Identify and maintain the skin smooth, supple, intact.

Expected outcomes:

• Good skin turgor, skin intact, no blisters, no redness.

Intervention:

• Observation reddish, pale.
• Use skin cream.
• Discuss the importance of changes in position, it is necessary to maintain the activity.
• Emphasize the importance of nutrient input / adequate fluid.

Dehydration

Definition

Dehydration is a condition in which a person who is not fasting experiencing or at risk of dehydration vascular, interstitial or intra-vascular (Sell Lynda Carpenito, 2000: 139).


Classification

Classification of dehydration by Donna D. Ignatavicus there are 3 types:

a. Isotonic dehydration
Isotonic dehydration is lost water followed by the electrolyte so that the density remained normal, then this type of dehydration is usually not result in ECF fluid move to the ICF.

b. Hypotonic dehydration
Hypotonic dehydration is the loss of solvent from the ECF exceeds fluid loss, resulting in blood vessels become more concentrated. ECF osmotic pressure decreases, resulting in fluid moves from the ECF to ICF. Vascular volume also decreased, as well as cell swelling occurs.

c. Hypertonic dehydration
Hypertonic dehydration is ECF fluid loss exceeds the solvent is non-osmotic dehydration ECF decreased, resulting in fluid moves from ICF to ECF.


Etiology

Various causes dehydration determine the types of dehydration (According to Donna D. Ignatavicus, 1991: 253).

1. Dehydration

• Bleeding.
• Vomiting.
• Diarrhea.
• Hypersalivation.
• Fistula.
• Ileustomy (cutting intestine).
• Diaporesis (excessive sweating).
• Burns.
• Fasting.
• Hypotonic therapy.
• Suction gastrointestinal (stomach wash).

2. Hypotonic Dehydration

• DM disease.
• Excess fluid rehydration.
• Severe and chronic malnutrition.

3. Hypertonic Dehydration

• Hyperventilation.
• Diarrhea water.
• Diabetes Insipedus (ADH hormone decreases).
• Excessive fluid rehydration.
• Dysphagia.
• Impaired thirst.
• Disorders of consciousness.
• Systemic infection: increased body temperature.

Clinical Manifestations

Here are the symptoms or signs of dehydration based on its level (Nelson, 2000):
1. Mild dehydration (loss of fluid 2-5% of its original weight)

• Thirsty, restless.
• Pulse rate 90 -110 x / minute, normal breath.
• Normal skin turgor.
• Urine output (1300 ml / day).
• Good awareness.
• Heart rate increased.

2. Moderate Dehydration (loss of fluid 5% of its original weight)

• Increased thirst.
• Rapid and weak pulse.
• Dry skin turgor, dry mucous membranes.
• Reduced urine output.
• Increased body temperature.

3. Severe dehydration (loss of fluids 8% of its original weight)

• Loss of consciousness.
• Weak, lethargic.
• Tachycardia.
• Sunken eyes.
• No urine output.
• Hypotension.
• Rapid pulse and smooth.
• Cold extremities.

Nursing Diagnosis and Interventions for Dehydration

Risk for Infection related to the invasion of microorganisms in the body

Goal : after the act of nursing for 3x24 hours of infection did not occur.

Expected outcomes:

• Patients will show a careful hand-washing techniques.
• Patients will be free of the nosocomial infection during hospitalization.
• Patients will demonstrate knowledge of the risk factors associated with infection and appropriate precautions to prevent infection.

Intervention - Risk for Infection:

1. Monitor for signs and symptoms of infection.
R /: To determine whether there is an infectious process.

2. Monitor laboratory results, Monitor the patient's temperature.
R /: Leukocyte increased and increased body temperature is not expected, a sign of infection.

3. Use antiseptic technique when taking action to clients.
R /: Prevent cross-infection.

4. Emphasize the need to wash hands regularly / thoroughly before and when handling food, after toileting.
R /: Many viruses such as cytomegalovirus (CMV) can be excreted in the urine for more than 4 years after exposure and possibly transmitted through poor hygienic.

5. Encourage clients to drink 6 to 8 glasses of fluid every day. Discuss the role of acidic residues in the diet and add juice or orange cranberr.
R /: Helps to acidify the urine and help prevent UTIs.

6. Encourage clients to try Kegel exercises (tightening the perineum) throughout the day.
R /: Fix support for pelvic organs, strengthen and increase the elasticity of the pubococcygeus muscle, better control urination.

7. Encourage the use of cotton underwear, and avoid using bath tub, if a client has a history of Urinary Tract Infections (UTIs).
R /: Static urinary and glycosuria may mempredisposisikan prenatal clients on a urinary tract infection or UTI, especially when history include urinary problems / kidney.

8. Get a routine urine sample for microscopic examination, pH, presence of leukocyte cells, and also culture and sensitivity, according to the indication. Report the number of colonies greater than one hundred thousand per milliliter.
R /: This is to detect the presence of microorganisms in the body. This is to detect the presence of microorganisms in the body. High leukocyte cell count is an indicator of infection.

9. Instruct the patient to always clean the areas that are reddish.
R /: Prevent the entry of other bacteria that can cause infection.

10. Collaboration with the medical team to provide antibiotics.
R /: Antibiotics can help fight infection.

Risk for Activity Intolerance related to physical weakness

Activity Intolerance is a decrease in physiological capacity to maintain activity to the level desired or required.


Defining Characteristics:

Major :

• Change the client's physiological response to the activity undertaken.
• Respiratory: dyspnea (breathing frequency increased exaggeration).
• Shortness of breath (decrease frequency).
• Pulse: weak, declining, excessive increase, the increase in the rhythm, failed to return to the level before the activity after 3 minutes.
• Blood pressure: failed to increase the activity, an increase in diastolic over 15 mmHg.

Minor:

• fatigue, 
• weakness, 
• cyanosis or pale, 
• mental chaotic, 
• vertigo

Subjective Data:

• weakness
• fatigue
• dyspnea
• lack of sleep

Objective Data :

Assess the strength and balance, the evaluation of an individual's ability to:

• Changing positions himself on the bed.
• Ambulation.
• Doing ADL (activity daily living) or daily activities.

Assess for the presence of:

• pale
• cyanosis
• mental chaotic
• vertigo

Nursing Interventions:

Activity intolerance related to physical weakness

Goal: after the act of nursing for 5 x 24 hours the patient does not experience injury.

Expected outcomes:

• The patient is able to identify risk factors and individual strengths that affect tolerance to activity.
• Participate in rehabilitation programs to improve the ability to move.
• Being able to choose several alternatives to maintain the level of activity.

Intervention:

1. Assess the level of the client's ability to exercise.
R /: As a base to provide an alternative and appropriate motion exercises with ability.

2. Plan on giving training program according to the ability of the patient.
R /: Exercise may increase the movement of muscles and stimulate blood circulation.

3. Provide a diet high in calcium.
R /: Helps replace calcium lost.

4. Teach the client on how to perform daily activities.
R /: To improve the movement and perform safe movement.

5. Involve the family to train the patient's mobility.
R /: To support the patient.

6. Consult with a physical therapist.
R /: Helpful in developing individualized exercise program and identify the need for a tool to eliminate muscle spasm, improving motor function, prevent / decrease atrophy and contractures in the muscular system.

(doengoes, 2000)

Nursing Diagnosis for Activity Intolerance

Nursing Care Plan for Febrile Seizures

According to Doengoes (1999: 259-261 and 871-872) includes:

History of causative factors:

• Idiopathic no cause is known.
• Post-trauma, head injury, inflammation of the lining of the brain, high fever.

History of seizures

• Since what age?
• How long seizures occur?
• How many times a seizure occurs within 1 hour?
• When was the last seizures experienced?

Physical examination, by inspection, palpation, percussion and auscultation.

a. Activity / rest.
Symptoms:

• Fatigue, general weakness.
• Limitations in activities / work caused by self-/ significant other / nursing care giver or others.

Signs:

• Change of tone / muscle strength.
• Involuntary movements / muscle contraction.

b. Circulation
Symptoms:

• Ictal: hypertension, increased pulse and cyanosis.
• Post-ictal: normal vital signs or depression with decreased pulse and respiration.

Signs:

• Heart sound: disratmia and development can lead to myocardial dysfunction, effects of acidosis / electrolyte imbalance.
• The skin is warm, dry, luminous, pale, moist, and mottled.

c. Ego integrity
Symptoms:

• Stressor external / internal related to the state and or a treatment.
• Receptors: feeling no / not helpless, changes in relationships.

Signs:

• Widening of emotional response.

d. Elimination
Symptoms:

• Episodic urinary incontinence.

Signs:

• Ictal: increased pressure bladder and sphincter tone.
• Post-ictal: muscle relaxation resulting in urinary incontinence.

e. Food / fluid
Symptoms:

• Sensitivity to food, anorexia, nausea, vomiting associated with seizure activity.

Signs:

• Weight loss, decreased subcutaneous fat.
• Decreased urine output concentration, progress towards oligoria and anuria.
• Soft tissue damage / teeth (injury during a seizure).
• Gingival hyperplasia.

f. Neurological
Symptoms:

• Headache, dizziness, fainting, history of head trauma, cerebral anoxia and infection.
• Post-ictal: weakness, muscle pain, paralysis area.

Signs:

• Anxiety, fear, mental chaotic, disorientation, delirium / coma.
• Involuntary movements / muscle contraction.

g. Pain / comfort
Symptoms:

• Headache, muscle pain / back to the post-ictal period abdominal seizures.
• Localization of pain / discomfort urticaria.

Signs:

• Attitude / behavior that careful changes in muscle tone.
• Agitated behavior.

h. Breathing
Symptoms:

• Ictal phase: teeth shut, cyanosis, decreased breathing rapidly, increased secretion mokus.
• Post-ictal phase: apnea.

Signs:

• Temperatures generally rising to 37.5 0C or more.
• Chills.

i. Security
Symptoms:

• History dropped / trauma or invoice.

Signs:

• Trauma to the soft tissue / ecchymosis overall decrease in muscle strength.

j. Interaction
Symptoms:

• Related interpersonal problems in the family or social environment.

k. Education / learning
Symptoms:

• A history of seizures or epilepsy in the family.
• The use of antibiotic drugs recently or long term.

Nursing Care Plan for Pediatric Febrile Seizures

Definition of Febrile Seizures

Febrile seizures are seizures that occur on the rise in body temperature (rectal temperature of more than 380C) which is caused by an extra-cranial process. Febrile seizures occur in 2-4% of children aged 6 months - 5 years. Children who have had seizures without fever, then re febrile seizures are not included in the febrile seizures. Febrile seizures in infants younger than 1 month are not included in the febrile seizures. When children aged less than 6 months or more than 5 years experience seizures preceded by fever, think of other possibilities, such as central nervous system infections, or epilepsy that happen to occur along a fever.


Etiology

Until now, the etiology of febrile seizures is not known with certainty. Fever is often caused by:

• upper respiratory tract infection,
• otitis media,
• pneumonia,
• gastroenteritis, and
• urinary tract infection.

Seizures are not always arise at high temperatures. Sometimes that is not so high can cause seizures.
Other causes of febrile seizures is the use of certain drugs such as diphenhydramine, tricyclic antidepressants, amphetamines, cocaine, and dehydration resulting in disruption of water-electrolyte balance.


Risk Factors

While the factors that affect febrile seizures are:
1. Age

• 3% of children under 5 years old have experienced febrile seizures.
• The highest incidence occurred in the age of 2 years and decreased after 4 years, rarely occurs in children under the age of 6 months or more than 5 years.
• The first attack usually occurs within the first 2 years and then declines with age.

2. Gender

• Febrile seizures are more common in boys than girls by a ratio of 2: 1. This may be caused by cerebral maturation faster in women than in men.

3. Body temperature

• The increase in body temperature is an absolute requirement of febrile seizures. High body temperature at the time of the attack raised seizure threshold value. Seizure threshold is different for each child, ranging between 38.3 ° C - 41.4 ° C. The big difference in this seizure threshold, explain why in a new child seizures arising after body temperature rises very high, while the other child has seizures arise even if the temperature increase is not too high. From this fact it can be concluded that the recurrence of febrile seizures will be more frequent in children with a low seizure threshold.

4. Heredity

• Heredity plays an important role for the occurrence of febrile seizures. Some authors found that 25-50% of children who have febrile seizures have family members (parents, siblings) who have experienced febrile seizures at least once.

Risk factor for febrile seizures first important thing is fever. Febrile seizures tend to arise within the first 24 hours at the time of illness with fever or during high fever.

Other Factors include:

• a history of febrile seizures in parents or siblings,
• delayed development,
• problems in the newborn period,
• children in special care, and
• low sodium levels.

After the first febrile seizure, approximately 33% of children will experience one or more recurrences, and approximately 9% of children experienced recurrence or 3 times more. The risk of recurrence increases with an early age, children quickly get after febrile seizures arise, low temperatures when convulsions, a family history of febrile seizures, and family history of epilepsy.

About 1/3 of children with first febrile seizure may experience recurrent seizures.
Risk factors for recurrent febrile seizures include the following:

• Young age when the first febrile seizure.
• Low temperature when the first seizure.
• Family history of febrile seizures.
• The duration between onset of rapid onset of fever and convulsions.

Patients with these risk factors have more than 70% chance of recurrence. Patients without these risk factors have less than 20% chance of recurrence.


Assessment - Nursing Care Plan for Febrile Seizures