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)