Assessment
Today, Ms.. W age 20, came to the hospital with complaints of high fever (39 0 C) since yesterday. Other complaints: headache, nausea, cough, also complained a few days no bowel movement, the client says insomnia and frequent waking, the client says weak to do an activity, the client complains of pain abdomen, the client says taste in the mouth, and body weakness. After vital sign and physical examination found data: blood pressure: 120/70 mmHg, pulse: 110 x / min, respiration: 30 x / min, typical tongue state (white, dirty, edges hyperemia, chapped lips, face red, lots of sweat). Then the client perform laboratory tests (test widal: 500, check full blood: leukocytes more than 500 / mm3, and SGOT-SGPT) all the results are positive. Client installed oxygenation, the client looks nervous, looking grimacing in pain, weakness, weight decreased, looks bedrest, and assisted activity, faecal mass palpable in the lower abdomen, the portion of food that is provided is not exhausted, vomiting. His family said earlier do not want to be taken to hospital because he felt the disease would heal itself but after the heat higher, clients increasingly anxious and eventually want to be taken to hospital. Also obtained information that the client's father had a history of hypertension.
5 Nursing Diagnosis for Typhoid Fever
Diagnoses that may appear on the client with Typhoid Fever are:
1. Risk for Fluid Volume Deficit related to hyperthermia, a lot of sweat and vomit
characterized by chapped lips, skin turgor ugly.
Goal: fluid volume imbalance does not occur
Expected outcomes:
Mucous membranes moist lips, vital signs (blood pressure, temperature, pulse, respiration) within normal limits, no signs of dehydration.
Intervention:
Assess for signs of dehydration such as dry mouth mucosa, inelastic skin turgor, and increased body temperature, monitor fluid intake and output in 24 hours, measuring body weight each day at a time and at the same time, the report noted such things as nausea, vomiting , stomach pain and distortion. Encourage clients to drink plenty of approximately 2000-2500 cc per day, collaboration in laboratory tests (Hb, Ht, K, Na, Cl) and collaboration with doctors in addition to via parenteral fluids as indicated.
2. Acute Pain
characterized by headache, clients complained of pain in the abdomen, and the patient appears grimaced in pain.
Goal: pain can be reduced.
Intervention:
Assess the location, pain scale, assess the client's ability to withstand pain, distraction, relaxation techniques do to relieve pain, perform a comfortable positioning, collaboration in providing analgesic.
3. Risk for Imbalanced Nutrition, Less Than Body Requirements related to inadequate intake and vomiting
characterized by drop in weight.
Goal: Risk nutrition less than body requirements not happen.
Expected outcomes:
Appetite increased, indicating a stable body weight / ideal, value bowel / intestinal peristalsis normal (6-12 times per minute) normal laboratory values, conjunctiva and mucous membranes pale lips.
Intervention:
Assess the client's nutritional patterns, assess eating likes and dislikes on the client, advise bed rest / activity restrictions during the acute phase, weights every day. Encourage clients to eat little but often, record or report things like nausea, vomiting, stomach pain and distention, collaboration with a nutritionist for dietary administration, collaboration in laboratory tests such as hemoglobin, hematocrit and albumin and collaboration with doctors in antiemetic drug.
4. Hyperthermia related to the infection of salmonella thypii
Purpose: Hyperthermia resolved.
Expected outcomes:
Temperature, pulse and respiration within normal limits, free from cold and no complications related to the problem of typhoid.
Intervention:
Observation of body temperature, encourage families to limit the activities of the client, give a cold compress on the area axila, groin, temporal when heat, encourage families to put on clothing that can absorb sweat like cotton, collaboration with physicians in the delivery of anti-pyretic.