Nursing diagnosis for encephalitis deseases frequently occur

Nursing Diagnosis for encephalitis deseases FREQUENTLY OCCUR
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Nursing Diagnosis for encephalitis deseases FREQUENTLY
OCCUR
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Encephalitis is an infection of the CNS caused by viruses or other microorganisms that are non purulent 1. High risk of infection associated with resistance to infection down.
2. High risk associated with changes in tissue perfusion Hepofalemia, anemia.
3. High risk of injury associated with seizure activity umu.
4. Pain b / d of the process of infection is characterized by the child crying, restless.
5. Impaired mobility is associated with decreased muscle strength are characterized by limited ROM.
6. Impaired nutrition less than body requirements related to nausea and vomiting.
7. Sensorimotor disturbances (vision, hearing, speech) are associated with damage to the central nervoussystem.
8. Impaired sense of comfort associated with headache nausea.
9. Impaired skin integrity risk associated with the body's defense against infection power down.
10. Risks associated with spastic contracture occurs repeatedly.
High risk of infection associated with resistance to infection downPurpose:- No infectionExpected outcomes:- The healing time with no evidence of spread of infection is endogenousIntervention1. Defense aseptic technique and proper hand washing techniques either officers . Monitor and limitvisitors.
rational: px reduce the risk of secondary infection. Source control the spread of infection, preventpemajaran in individuals who experience nfeksi upper respiratory tract.
2. Abs. temperature regularly and clinical signs of infection.
rational: Early detection of signs of infection is an indication of the development of Meningkosamia.
3. Give antibiotics if indicatedrational: Drugs are selected depending on the type of infection and sensitivity of the individual.
High risk of trauma associated with generalized seizure activityPurpose: Nursing Diagnosis for encephalitis deseases FREQUENTLY OCCUR
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Expected outcomes:- Not having a seizure / broadcaster other injuries Intervention:1. Provide security for patients by giving pads, barrier attached tetapn bed and give a booster in themouth, the airway remains free.
rational: Protecting px case of seizures, oral booster somewhat tongue is not bitten.
Note: when entering the mouth wedge mouth just relaxation.
2. Maintain bed rest in the acute phase.
rational: Reduce the risk of falls / trauma during the vertigo.
3. Collaboration.
Give the drug as an indication like delantin, valum etc.
rational: It is indicated for the treatment and prevention of seizures.
4. Abservasi vital signsrational: Detection of seizures themselves somewhat to do follow-up.
Nursing Diagnosis III
Risk of contractures b / d spastic seizures recur Purpose:- Not going contracturesKtiteria results:- Did not happen joint stiffness- Can move the limbs 1. Provide a description of the client's mother about the cause of the spastic, joint turmoil.
2. Perform passive exercises began gradually end knucklesrational: Exercising relaxes muscles, preventing the contractor.
3. Make changes position every 2 hoursrational: the expected position changes per / usi smoothly into the network, enhancing the body'sdefenses.
4. Observation kaerdinal symptoms every 3 hoursrational: With observations can make early detection of abnormalities can be done when there isimmediate intervention5. Collaboration for spastic medication administration dilantin / valium according Indicationrational: Given dilantin / valium, if there is recurrent spastic seizures _______________________________________________ Nursing Diagnosis for encephalitis deseases FREQUENTLY OCCUR
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Nursing Diagnosis for encephalitis deseases FREQUENTLY
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