Hyperthermia and Acute Pain - NCP for Mastoiditis

 Nursing Care Plan for Mastoiditis

Mastoiditis is an inflammation of the mastoid bone, usually from the tympanic cavity. The expansion of middle ear infections repeatedly can cause changes in the mastoid, such as thickening of the mucosa and accumulation of exudate. Over time there is inflammation of the bone (osteitis) and collecting exudate / pus that more and more, eventually finding a way out. The weak areas are usually located behind the ear, causing an abscess superiosteum.

According to George (1997: 106), the clinical manifestations in patients with mastoiditis include:

• The fever usually disappear and arise.
• Pain tends to settle and throbbing, located around and inside the ears, and experience tenderness in the mastoid.
• Hearing loss.
• Tympanic membrane bulging contain skin that has been damaged and discuss sebaceous (fat).
• Posterior canal wall hanging.
• Postauricular swelling.
• A large discharge through the ear canal and the odor.

Nursing Diagnosis and Interventions for Mastoiditis

1. Acute Pain is related to inflammation of the mastoid bone because of infection.

Goal: Pain is resolved.

Expected outcomes:

• Pain is reduced.
• Pain scale decreased.
• The face looked relaxed.

Interventions :

1. Review the scale of pain, location, intensity.
R /: Knowing the effectiveness of interventions.

2. Provide a comfortable position.
R /: Reduce pain.

3. Teach relaxation techniques and create a tranquil environment.
R /: Turning his attention to the pain and reduces pain.

4. Collaboration of analgesics, antibiotics, and anti-inflammatory as indicated.
R /: It can reduce pain, kill germs and reduce inflammation and accelerating healing.


2. Hyperthermia related to the inflammatory process.

Goal: The body temperature may be normal (36 0- 37 0 C)

Expected outcomes:

• The body temperature within normal range (36 0-37 0 C).
• The skin does not feel warm.
• The face does not look red.
• Prevent dehydration.

Interventions :

1. Monitor the input and output.
R /: To find out the patient's fluid balance.

2. Measure the temperature every 4-8 hours.
R /: To determine the condition of the client's body temperature.

3. Teach warm compresses, and a lot of drinking
R /: To reduce body heat and replace lost body fluids.

4. Collaboration with the administration of antipyretics.
R /: To reduce the heat.

Source : Hyperthermia and Acute Pain - NCP for Mastoiditis - Nursing Care Plan (free-nursingcareplan.blogspot.com)

Hyperthermia related to Neonatal Sepsis

 Nursing Diagnosis and Interventions for Neonatal Sepsis

Sepsis is a syndrome characterized by clinical signs and symptoms of severe infection that can progress toward septicemia and septic shock. (Doenges, 1999)

While neonatal sepsis is a severe infection that affects neonates with systemic symptoms and there are bacteria in the blood. Neonatal sepsis course of the disease can take place quickly so often not monitored, without adequate treatment babies can die within 24 to 48 hours. (Surasmi, 2003).


Nursing Diagnosis and Interventions for Neonatal Sepsis

Hyperthermia related to damage control temperature, secondary to infection or inflammation.

Expected outcomes:

• The body temperature within normal limits.
• Pulse and breathing frequency within normal limits.

Intervention and Rationale:

1. Monitoring of vital signs every two hours and monitor skin color.
R /: Changes in vital signs that would significantly affect the regulatory processes or metabolism in the body.

2. Observation of seizures and dehydration.
R /: Hyperthermia potential to cause seizures that will worsen the patient's condition and can cause the patient to lose a lot of fluid in the evaporation of an unknown number and can cause the patient goes into a state of dehydration.

3. Give compress with warm water in the axilla, neck and groin, avoid using alcohol to compress.
R /: Compress the axilla, neck and groin are large blood vessels, which helps reduce fever. The use of alcohol is not done because it will cause a decrease and an increase in heat drastically.

4. Collaboration: Give antipyretics as needed if the heat does not go down.
R /: Giving antipyretics are also required to reduce the heat immediately.


Nursing Care Plan for Hyperthermia

Source : Hyperthermia related to Neonatal Sepsis - Nursing Care Plan (free-nursingcareplan.blogspot.com)

Disturbed Body Image related to Rheumatoid Arthritis

 Nursing Care Plan for Rheumatoid Arthritis

Rheumatoid arthritis is a disease which has long been known and spread throughout the world and involving all races and ethnic groups. Rheumatoid arthritis is often found in women, with the ratio of women to men is 3: 1. The tendency for women suffering from rheumatoid arthritis and remissions are common in women who are pregnant, this raises the suspicion of the presence of hormonal balance factor as one of the factors that affect this disease.

Most patients show symptoms of chronic intermittent disease, which if left untreated will cause damage to joints and progressive joint deformity that causes disability and even premature death.

Disturbed Body Image related to changes in the ability to perform the duties of a general, an increase in energy use, the imbalance of mobility.

Evidenced by:

• Changes in the function of diseased body parts.
• Focus on past strength and appearance.
• Changes in lifestyle / physical ability to continue the role, job loss, dependence on the nearest person.
• Changes in social engagement; a feeling of isolation. Feelings of helplessness, hopelessness.

Expected outcomes: The patient will :

• Expressing increased confidence in the ability to cope with illness, changes in lifestyle, and possible limitations.
• Develop a realistic plan for the future.

Intervention and Rationale

1. Encourage disclosure about the problem of the disease process, hope for the future.
R /: Give the opportunity to identify the fear / misconceptions and deal with it directly.

2. Discuss the meaning of loss / change in patients / people nearby. Ascertain how the patient's personal views on the functioning of day-to-day lifestyle.
R /: Identify how the disease affects self-perception and interaction with others will determine the need for intervention / counseling further.

3. Discuss the patient's perception of how the people closest to accept limitations.
R /: Gestures verbal / non-verbal people nearby can have a major influence on how the patient sees himself.

4. Acknowledge and accept the feelings of the bereaved, hostile, dependency.
R /: constant pain would be exhausting, and feelings of anger and hostility are common.

5. Pay attention to the behavior of withdrawing, denying use or too noticed a change.
R /: Can demonstrate emotional or maladaptive coping methods, requiring further intervention.

7. Involve patients in the treatment plan and schedule of activities.
R /: Increase the feeling of self-esteem, encourage independence, and encourage participation in therapy.

8. Assist in need of care required.
R /: Maintaining the appearance that can improve self-image.

9. Provide positive support when necessary.
R /: Allows patients to feel good about themselves. Reinforcing positive behavior. Increase confidence.

10. Collaboration: Refer to psychiatric counseling, eg specialist psychiatric nurse, psychologist.
R /: Patient / person nearby may need support for dealing with long-term process / incapacity.

11. Collaboration: Give medicines as directed, eg; antianxiety drugs and mood enhancer.
R /: It may be required at the time of the advent of the Great Depression, until the patient increases coping abilities more effectively.

Nursing Diagnosis for Rheumatoid Arthritis

 

Source : Disturbed Body Image related to Rheumatoid Arthritis - Nursing Care Plan (free-nursingcareplan.blogspot.com)