Nursing Care Plan for Rheumatic Fever in Children


Nursing Care Assessment

Based on the information Nelson (2000), the data could focus on assessment of nursing care, among others:

1. Focus data :
  • Increased body temperature usually occur in the afternoon.
  • A history of respiratory tract infection.
  • Decreased blood pressure, increased pulse rate, respiration increases.
  • Non-productive cough.
  • Epistaxis.
  • Abdominal pain.
  • Arthralgia.
  • Loss of appetite.
  • Losing weight.

2. Specific manifestations:

Carditis:
  • tachycardia
  • cardiomegaly
  • voice murmurs
  • changes in heart sound
  • ECG changes (PR lengthwise)
  • precordial pain
  • pericardial friction rub
Polyarthritis
  • joint swelling, heat, redness, tenderness.
  • spread on the knee joint, elbow, shoulder, arm.

Subcutaneous nodules:
  • swelling of the skin, soft palpable.
  • coming shortly, in general readily absorbed.
  • found on the extensor surfaces of the joints

Chorea:
  • irregular movements of the extremities, involuntary.
  • involuntary facial expressions
  • speech disorders
  • emotional lability
  • muscle weakness
  • muscle tension when anxious, lost when the break.
Erythema marginatum:
  • reddish macular common on the torso and palms.
  • the macula can not be permanently relocates à
  • the macula is non pruritus

Nursing Diagnosis for Rheumatic Fever in Children

1. Knowledge Deficit : parents / child related to treatment, the activity restriction, the risk of cardiac complications.

Goal: complications did not occur and parents understand the child's disease.

Interventions:
  • Auscultation of heart sounds to detect changes in rhythm.
  • Give antibiotics according to the program.
  • Restriction of activity to the clinical manifestations of rheumatic fever does not exist, and provide rest periods.
  • Provide play therapy is appropriate and does not make patients tired.
  • Give knowledge on mother and child about the disease and treatment procedures.


2. Ineffective individual coping related to disease conditions.

Goal: child understands about treatment procedures and can be cooperative, individual kooping effective.

Interventions:
  • Assess the desire to play according to the age and condition.
  • Create a schedule of activity and rest.
  • Teach for participation in activities of daily necessities.
  • Teach children / parents do not realize that the movement is associated with chorea and temporary.

4. Pain related to polyartritis.

Goal: lost and diminished pain.

Expected outcomes: child can control pain and mild pain scale of 2-3.

Interventions:
  • Assess pain scale (1-10).
  • Giving analgeik, anti-inflammatory and antipyretic according to the program.
  • Repositioning to reduce joint stress.
  • Give warm and cold treatment on a sore joint.
  • Teach technique of distraction / relaxation for example; relaxation techniques and fantasy.

5. Risk for injury related to streptococcal infection.

Goal injury did not occur.

Interventions:
  • Monitor the temperature every 4 hours during treatment.
  • Give antibiotics according to the program.
  • See also in discharge planning.
  • Rest patients of activities that can make you tired.

Komentar

Posting Komentar

Postingan populer dari blog ini

NCP Post Traumatic Stress Disorder

DSM-IV 309.81 Posttraumatic stress disorder (specify acute, chronic, or delayed onset) 308.3 Acute stress disorder An anxiety disorder resulting from exposure to a traumatic event in which the individual has experienced, witnessed, or been confronted with an event or events that involve actual or threatened death/serious injury or a threat to the physical integrity of the self or others. The
Baca selengkapnya

Nursing Care Plan for Dehydration

Gambar
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 dehydratio...
Baca selengkapnya

Nursing Care Plan for Cesarean Section

Nursing Care Plan for Cesarean Section (Cesarean Birth)| Cesarean Section Overview; Cesarean Section Overview A Caesarean section, (also called C-section, Caesarian section, Cesarean section, Caesar, etc.) is a surgical procedure in which one or more incisions are made through a mother's abdomen (laparotomy) and uterus (hysterotomy) to deliver one or more babies, or, rarely, to remove a
Baca selengkapnya