NCP Hirschsprung's Disease : Assessment, Nursing Diagnosis and Interventions
Nursing Care Plan for Hirschsprung's Disease
Assessment of Hirschsprung's Disease
1. Activity / rest
Nursing Diagnosis and Interventions for Hirschsprung's Disease - Preoperative
1. Altered Bowel Elimination: observations related to hypertrophy and distention of the proximal colon.
Goal: Observation does not happen.
Outcomes:
Interventions:
1 Assess the client's pattern of elimination.
R /: Identify custom client to facilitate further action.
2 Encourage clients to drink water from 1500 to 2000 cc / day.
R /: Adequate fluid intake can improve the balance between absorption in the colon and fluid intake, thereby preventing the formation of a hard feeces.
2. Imbalanced Nutrition: Less Than Body Requirements related to intake less.
Goal: Fulfillment of nutrients can be resolved.
Outcomes:
1 Monitor food intake.
R /: Adequate intake affect the healing process.
2 Provision of adequate calories and balanced meals.
R /: Caloric intake helps the body to maintain homeostasis.
3 Encourage clients to spend a portion of their food.
R /: Adequate intake can assist in improving the general state of the client.
3. Anxiety related to ineffective coping.
Goal: Anxiety is resolved.
Outcomes:
1 Assess the level of anxiety.
R /: Make it easy for the next action.
2 Give the opportunity to the clients and their families to express his feelings.
R /: Thus the client and his family was relieved to express feelings.
Nursing Diagnosis and Interventions for Hirschsprung's Disease - Postoperative
1. Acute Pain related to the continuity of body tissues.
Goal: The client expresses a sense of comfort pain reduced / lost.
Outcomes:
Interventions:
1 Assess and record the location and duration of pain.
R /: Knowing the client's perception and reaction to pain as an effective basis for further intervention.
2 Give a fun position.
R /: Reduce emphasis on muscle and prevent muscle spasms that can cause pain.
3 Observation of vital signs every 2 hours.
R /: Practice deep breathing slowly and regularly will help to relax the muscles so that the supply of O2 to the tissue smoothly, thus reducing pain.
4 Implementation of appropriate analgesic drug administration programs.
R /: Analgesic serves to inhibit stimuli that are not perceived pain, so that pain is reduced / lost.
2. Disturbed Sleep Pattern related to postoperative wound pain.
Goal: Sleep patterns resolved.
Outcomes:
1 Assess sleep patterns and intirahat clients.
R /: Knowing the disturbance of rest / sleep clients to determine further intervention.
2 Create a pleasant environment.
R /: A quiet environment can provide peace to rest and sleep.
3 Encourage clients to a lot of rest and enough sleep.
R /: Adequate sleep can give a fresh taste to the clients and accelerate the healing process.
Assessment of Hirschsprung's Disease
1. Activity / rest
- Symptoms: Malaise, changing patterns of rest / sleep associated with pain, limitations.
- Symptoms: Anxiety, fear, feelings of helplessness parents.
- Symptoms: Constipation can be accompanied by diarrhea.
- Symptoms: Abdominal distension progressively, until the thin abdominal wall veins visible, peristaltic activity can be observed.
- Symptoms: Anorexia, nausea, vomiting, weight loss.
- Signs: Decrease subcutan fat / muscle mass, weakness, a sign of malnutrition and growth failure.
- Symptoms: Abdominal pain.
- Signs: Facial expressions grimacing, moaning / crying, behavioral distraction, abdominal tenderness / distension.
- Parent questions related to the disease, care and treatment of children.
- Patient's discharge plan: Requires assistance / demonstration how irrigation and colostomy care, the ability to assess the incidence of abdominal distension and obstruction.
Nursing Diagnosis and Interventions for Hirschsprung's Disease - Preoperative
1. Altered Bowel Elimination: observations related to hypertrophy and distention of the proximal colon.
Goal: Observation does not happen.
Outcomes:
- Clients say can defecate.
- Normal intestinal peristalsis.
Interventions:
1 Assess the client's pattern of elimination.
R /: Identify custom client to facilitate further action.
2 Encourage clients to drink water from 1500 to 2000 cc / day.
R /: Adequate fluid intake can improve the balance between absorption in the colon and fluid intake, thereby preventing the formation of a hard feeces.
2. Imbalanced Nutrition: Less Than Body Requirements related to intake less.
Goal: Fulfillment of nutrients can be resolved.
Outcomes:
- Clients no nausea and vomiting.
- Inkate adequate.
- Clients are not weak.
1 Monitor food intake.
R /: Adequate intake affect the healing process.
2 Provision of adequate calories and balanced meals.
R /: Caloric intake helps the body to maintain homeostasis.
3 Encourage clients to spend a portion of their food.
R /: Adequate intake can assist in improving the general state of the client.
3. Anxiety related to ineffective coping.
Goal: Anxiety is resolved.
Outcomes:
- Cheerful facial expressions.
- Clients and their families are not asked again about his illness.
- Clients and their families have hope of recovery.
1 Assess the level of anxiety.
R /: Make it easy for the next action.
2 Give the opportunity to the clients and their families to express his feelings.
R /: Thus the client and his family was relieved to express feelings.
Nursing Diagnosis and Interventions for Hirschsprung's Disease - Postoperative
1. Acute Pain related to the continuity of body tissues.
Goal: The client expresses a sense of comfort pain reduced / lost.
Outcomes:
- Clients complained of pain at the surgical wound.
- Cheerful facial expressions.
- Vital signs within normal limits.
- Relationships within normal limits.
Interventions:
1 Assess and record the location and duration of pain.
R /: Knowing the client's perception and reaction to pain as an effective basis for further intervention.
2 Give a fun position.
R /: Reduce emphasis on muscle and prevent muscle spasms that can cause pain.
3 Observation of vital signs every 2 hours.
R /: Practice deep breathing slowly and regularly will help to relax the muscles so that the supply of O2 to the tissue smoothly, thus reducing pain.
4 Implementation of appropriate analgesic drug administration programs.
R /: Analgesic serves to inhibit stimuli that are not perceived pain, so that pain is reduced / lost.
2. Disturbed Sleep Pattern related to postoperative wound pain.
Goal: Sleep patterns resolved.
Outcomes:
- Clients sleep 7-8 hours.
- Clients seem cheerful.
1 Assess sleep patterns and intirahat clients.
R /: Knowing the disturbance of rest / sleep clients to determine further intervention.
2 Create a pleasant environment.
R /: A quiet environment can provide peace to rest and sleep.
3 Encourage clients to a lot of rest and enough sleep.
R /: Adequate sleep can give a fresh taste to the clients and accelerate the healing process.
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