Nursing Diagnosis : Altered Levels of Consciousness related to the process of infection and neurological impairment.
Goals:
- Level of client awareness, getting back to normal.
- No physical injury.
- GCS within normal limits (Normal 15).
- Good awareness.
- Orientation to time, place and person.
- Vital signs within normal limits.
- Monitor neurologic status regularly and compare it to the normal state, such as GCS.
- Assess motor response to commands performed by nurses.
- Evaluation of the ability to open the eyes, such as spontaneous (fully conscious), open only if given a painful stimulus or closed (comma).
- Assess verbal response: note whether the client aware, orientation to person, place, and time well or even confused using words.
- Assessment of the trend of changes in the level of awareness and increase the potential of ICT is very useful in determining the location, the spread. (Doenges, p. 273)
- Measuring the overall situation and the best clue to the client state of consciousness that his eyes closed. (Doenges, p. 273)
- Determining the level of consciousness. (Doenges, p. 273)
- Measuring agreement in speech and show the level of consciousness. If damage occurs very little of the cerebral cortex, the client will probably respond well to verbal stimuli were given but may also exhibit such severe drowsiness or uncooperative. (Doenges, p. 273)
Nursing Diagnosis : Increased body temperature related to the inflammatory response of the central nervous system.
Goal :
- Maintain body temperature within normal limits.
Expected outcomes:
- The client no fever.
- The body temperature of 36 ° C - 37.5 ° C
- Vital signs within normal limits.
- The cliens are not seizures because of a high fever.
Nursing Interventions:
- Monitor the client's body temperature (degrees and patterns).
- Monitor the temperature of the environment, limit or add bed linen as indicated.
- Give a cold compress on axila and groin when the fever.
- Collaboration: administration of antipyretic drugs.
- Temperature of 38 0 to 41.1 0 C showed an acute infectious disease process.
- Fever patterns can help in the diagnosis. (Doenges, p. 875)
- Room temperature or amount of blankets should be changed to maintain near-normal temperatures. (Doenges, p. 876)
- With cold compresses can help reduce fever. (Doenges, p. 876)
- To reduce fever in the hypothalamus, although the fever may be useful in limiting the growth of the organism and increase auto destruction of infected cells. (Doenges, p. 876)
Nursing Diagnosis : Ineffective airway clearance related to neuromuscular damage.
Goal:
- Maintain normal breathing patterns or effective.
- The client is not breathlessness.
- The client does not cyanosis.
- SaO2 normal (95-100%).
- Give oxygen, according to clients' requirements.
- Change position periodically and ambulation and discharging.
- Suction with extra careful not more than 10-15 seconds. Note the character, color and turbidity of secretions.
- Maximizing oxygen in arterial blood and helps in the prevention in the prevention of hypoxia. (Doenges, p. 278)
- Increasing the air filling the entire lung segment, mobilizing and discharging. (Doenges, p. 448)
- Sucking is usually required if the client coma or in a state of immobilization and can not clear the airway. Sucking on a deeper trachea should be done with extra caution because it can cause or increase the hypoxic vasoconstriction in the end will cause considerable influence on cerebral perfusion. (Doenges, p. 278)
Nursing Diagnosis : Imbalanced Nutrition Less than Body Requirements related to changes in the ability to digest nutrients.
Goals:
- Nutrition of the client are met.
- Not experience signs of malnutrition.
- The client may spend a portion of the food provided.
- The increase in weight than before.
- Give fluids via IV or food through a tube.
- Give nutritional therapy in a hospital treatment program as indicated.
- Destroy and give food through any hose left on the tray after a period of time of administration as indicated.
Rational:
- To provide replacement fluids and eating well, if the client is not able to enter anything by mouth. (Doenges, p. 305)
- Treatment of the basic problems do not occur without improvements in nutritional status. Hospitalizations provide an environment where the control input of food, vomiting or elimination, medication and activity can be monitored. (Doenges, p. 428)
- Used as part of behavior change programs to provide your total calorie intake needed. (Doenges, p. 428)
