Nursing Care Plan for Hypospadias
Nursing Diagnosis for Hypospadias : Risk for Infection
Definition:
The increase in the risk of being attacked by disease organisms.
Defining characteristics:
Chronic disease.
- Inadequate immunity.
- The main defense inadequate (eg, skin damage, tissue injury, a reduction in the action, a change in the secretion of PH, change the peristaltic motion).
- The second defense inadequate (reduced hemoglobin, leukopenia, response to press something that causes inflammation).
- Added the opening of the environment on the pathogen.
- Pharmaceutical agents (ex: substances that inhibit the immune response).
- Amniotic membrane rupture prematurely.
- Extend split on amniotic membrane.
- Trauma / seriously injured.
- Tissue destruction.
NOC
- Immune status.
- Infection control.
Goal:
After nursing action for 2x24 hours the client is able to:
1. Shows the immune status, with indicators:
- The absence of recurrent infections,
- The absence of a tumor,
- Skin test reaction to the opening match,
- Solute in antibody levels in the normal range.
- Describe the transmission mode,
- Describe factors that accompany the transmission,
- Describe the signs and symptoms,
- Describe the activities increase resistance to infection.
NIC
Infection Control
- Limit the number of visitors.
- Use anti-microbial soap to wash hands properly.
- Wash hands before and after patient care.
- Use the general rule.
- Use clean gloves.
- Keep the environment in order to remain sterile for insertion in bed.
- Keep sterile environment to stay when changing channels.
- Close / maintain the confidentiality of the system when performing invasive hemodynamic examination.
- Change peripheral IV and cuddled by the CDC guidance.
- Make sure the sterile state, while doing IV.
- Proper nutrition intake.
- Increase fluid intake right.
- Perform appropriate antibiotic therapy.
- Teach wash hands to improve personal health.
- Teach proper handwashing techniques.
- Teach patients and families about the signs and symptoms of infection and when to report on the health care team.
- Teach patients to take antibiotics as prescribed.
Nursing Diagnosis for Hypospadias : Acute Pain
Acute Pain Definition:
Feel less happy, relieved, and perfect in the physical, psychospiritual, environmental and social.
Defining characteristics:
- Anxiety.
- Crying.
- Disruption of sleep patterns.
- Fear.
- Inability to relax.
- Irritability.
- Whimpered.
- Reported feeling cold.
- Reported feeling the heat.
- Reported feeling uncomfortable.
- Reported less than happy with the situation.
- Restless.
Related factors:
- Disease-related symptoms.
- Inadequate sources (eg financial and social support).
- Less environmental control.
NOC
- The level of comfort.
- Level of anxiety.
Goal:
After nursing action for 2x24 hours the client is able to:
1. Demonstrate a level of comfort with the indicator:
- Reported physical wellbeing.
- Reported satisfaction with symptom control.
- Reported psychological wellbeing.
- Expressing satisfaction with the physical environment.
- Expressing satisfaction with social relationships.
- Expressing spiritual satisfaction.
- Reported satisfaction with the level of freedom.
- Expressing satisfaction with pain control.
- Demonstrate flexibility role.
- Family show.
- The flexibility of the role of its members.
- Involve the family in making decisions angoota.
- Expressing feelings and emotional freedom.
- Demonstrate stress reduction strategies.
NIC
Pain Management
- Observation of nonverbal reactions of discomfort.
- Perform a comprehensive pain assessment, including the location, characteristics, duration, frequency, scale, quality and precipitation factors (muscle that has not been moved).
- Take action to improve the comfort of relaxation, ie. massage, posture, relaxation techniques.
- Use hot and cold techniques as recommended to minimize the pain.
- Choose variation of the size of the treatment (pharmacological, non-pharmacological, and only between personal relationships) to reduce pain.
- Teach for use of non-pharmacological techniques (such as: biofeddback, TENS, hypnosis, relaxation, music therapy, distraction, play therapy, acupressure, apikasi warm / cold, and massage) before, after and if possible, during the peak of pain, before the pain occurs or increased, and all the pain was still measurable.
- Monitor patient acceptance of pain management.
Decrease Anxiety
- Use soothing approach.
- State clearly the expectations of the patient.
- Accompany patients to provide security and reduce fear.
- Encourage the family to accompany the child.
- Perform a back / neck rub.
- Listen attentively.
- Identify the level of anxiety.
- Help patients recognize situations that cause anxiety.
- Encourage the patient to express feelings, fears, perceptions.
- Give medication to reduce anxiety.
Collaboration
- Collaborate with your doctor if any complaints of pain and unsuccessful action.
- Collaboration surgical procedure: The release of chordee and tunneling. Uretroplasty.
Health Education
- Provide factual information about the diagnosis, prognosis action Pressure Management,
- Explain all procedures and what is felt during the procedure.
- Instruct the patient to use relaxation techniques.
Source :
http://nurse-books.blogspot.com/2015/01/nursing-care-plan-for-child-with.html
http://nurse-books.blogspot.com/2015/01/risk-for-infection-related-to.html