Nursing Diagnosis for Tetanus : Hyperthermia related to efeks toxin (bacteremia)
Hyperthermia
Definition: The body temperature rises above the normal range.
Characteristics :
The symptoms of tetanus :
Purpose: Normal body temperature
Criteria: 36-37 ° C, the results of laboratory white blood cells (leukocytes) between 5.000-10.000/mm3
Nursing Interventions for Hyperthermia related to - Tetanus
1. Set the temperature a comfortable environment
Rational: the environment can affect the condition and temperature of individual body as a process of adaptation through the process of evaporation and convection.
2. Monitor body temperature every 2 hours
Rational: Identify the symptoms progress toward exhaution shock.
3. Provide adequate hydration or adequate drinking
Rational: Fluids help refresh the body and is a compression body from within.
4. Take action aseptic and antiseptic techniques in wound care.
Rational: Nursing wounds eliminate the possibility of toxins that are still located around the wound.
5. Give cold compress if no seizures occur external stimuli.
Rational: cold compress is one way to lower body temperature by means of conduction process.
6. Implement programs and antipiretic antibiotic treatment
Rational: These drugs can have broad spectrum antibacterial to treat gram-positive or gram negative bacteria. Antipiretic worked as a process of thermoregulation to anticipate an increase in body temperature.
7. Collaborative laboratory examination of leukocytes.
Rational: Test results leukocyte increased by more than 10,000 / mm 3 indicates infection and treatment or to follow the development of the programmed.
Hyperthermia
Definition: The body temperature rises above the normal range.
Characteristics :
- Increase in body temperature above the normal range
- Attacks or convulsions (seizures)
- Skin redness
- Increase respiratory rate
- Tachycardia
- Hands felt warm to the touch
The symptoms of tetanus :
- Lockjaw
- Stiff neck
- Seizures or spasms
- Inability to swallow
- Fever
- High blood pressure
Purpose: Normal body temperature
Criteria: 36-37 ° C, the results of laboratory white blood cells (leukocytes) between 5.000-10.000/mm3
Nursing Interventions for Hyperthermia related to - Tetanus
1. Set the temperature a comfortable environment
Rational: the environment can affect the condition and temperature of individual body as a process of adaptation through the process of evaporation and convection.
2. Monitor body temperature every 2 hours
Rational: Identify the symptoms progress toward exhaution shock.
3. Provide adequate hydration or adequate drinking
Rational: Fluids help refresh the body and is a compression body from within.
4. Take action aseptic and antiseptic techniques in wound care.
Rational: Nursing wounds eliminate the possibility of toxins that are still located around the wound.
5. Give cold compress if no seizures occur external stimuli.
Rational: cold compress is one way to lower body temperature by means of conduction process.
6. Implement programs and antipiretic antibiotic treatment
Rational: These drugs can have broad spectrum antibacterial to treat gram-positive or gram negative bacteria. Antipiretic worked as a process of thermoregulation to anticipate an increase in body temperature.
7. Collaborative laboratory examination of leukocytes.
Rational: Test results leukocyte increased by more than 10,000 / mm 3 indicates infection and treatment or to follow the development of the programmed.
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