Tuesday, May 20, 2014

NCP Cholera - 6 Nursing Diagnosis and Interventions

Nursing Care Plan for Cholera

Cholera Definition :

Cholera is an infection of the small intestine that is caused by the bacterium Vibrio cholerae. The main symptoms are profuse watery diarrhea and vomiting. Transmission is primarily through consuming contaminated drinking water or food. The severity of the diarrhea and vomiting can lead to rapid dehydration and electrolyte imbalance. Primary treatment is with oral rehydration solution and if these are not tolerated, intravenous fluids. Antibiotics are beneficial in those with severe disease. Worldwide it affects 3–5 million people and causes 100,000–130,000 deaths a year as of 2010. Cholera was one of the earliest infections to be studied by epidemiological methods.

Nursing Assessment for Cholera

  1. Assess the status of dehydration (skin color, temperature, acral, skin turgor, mucous membranes, eyes, crown, body temperature, pulse, respiration, behavior, weight loss).
  2. Observe for manifestations of acute diarrhea
    • A sudden attack of diarrhea
    • Fever
    • Anorexia, nausea, vomiting
    • Weight loss
    • Pain and abdominal cramps, abdominal distension
    • Increased bowel sounds / hyper-peristaltic
    • Malaise
    • Bowel movements more than 3 times a day, liquid stool consistency, with / or without mucus and blood
  3. Assess the psychosocial status of families
  4. Assess the level of knowledge of family
    • Knowledge of diarrhea at home
    • Knowledge of dietary
    • Knowledge about the prevention of recurrent diarrhea

Nursing Diagnosis for Cholera

  1. Deficient fluid volume related to excessive fluid loss through the stool or emesis
  2. Imbalanced Nutrition: Less Than Body Requirements related to loss of fluids through diarrhea, inadequate intake
  3. Risk for infection related to microorganisms that penetrate the gastrointestinal tract.
  4. Impaired Skin Integrity: perianal, related to irritation from diarrhea
  5. Anxiety related to separation from parents, unfamiliar environment, a stressful procedure.
  6. Interrupted Family Processes related to crisis situations, lack of knowledge about diseases, treatment of clients.

Nursing Interventions for Cholera

Deficient fluid volume related to excessive fluid loss through the stool or emesis

Goal :
  • Maintain adequate hydration
Expected outcomes:

No signs of dehydration: elastic skin turgor, sunken fontanel not, the patient is not agitated, mucous membranes moist, no weight loss.

Nursing Interventions and Rational:
1) Record Intake Output every 24 hours.
R / Knowing the status of dehydration and evaluate the effectiveness of interventions.

2) Measure the child's weight every day.
R / observe dehydration.

3) Measure vital signs and evaluation of skin turgor, mucous membranes, mental status.
R / observe dehydration.
4) Tell the family to give the child a drink gradually.
R / improve hydration.

5) Give oral rehydration solution (ORS).
R / rehydration and replacement of fluid loss through the stool.

6) Provide and monitor IV fluids as indicated (collaboration).
R / replacement fluid loss.

7) Observe the results of the electrolyte.
R / know the level of hydration and the effectiveness of interventions.

Imbalanced Nutrition: Less Than Body Requirements related to loss of fluids through diarrhea, inadequate intake

Goal :
  • consume adequate nutrition intake.
Expected outcomes:
  • No weight loss (weight stable)
  • Eating out 1 serving.
  • No nausea, vomiting.

Nursing Interventions and Rational:

1) Evaluation of nutritional status and weight loss
R / Identifying the need for further intervention.

2) Notify and motivation of mothers / families to continue breast-feeding.
R / breast milk reduces the severity and duration of disease and provide additional nutrients.

3) Tell the mother to give the child to eat small meals but often
R / increase food intake.

4) Observe and record the response to feeding.
R / know the tolerance of feeding.

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