Nursing Intervention:
1. Assess nutritional history, including a preferred food. Observation and record food intake.
Rationale: This action is to monitor caloric intake or lack of quality of food consumption.
2. Give a little and eat the right foods of little extras.
Rationale: This action is gastric dilatation can occur when feeding too quickly after a period of anorexia.
3. Maintain a schedule of regular weighing.
Rationale: This action is overseeing the effectiveness of weight loss or nutrition intervention.
4. Discuss the food and input in a pure diet.
Rationale: this action is to increase the input, increase the sense of participation / control diet.
5. Observation and record the occurrence of nausea / vomiting, and other symptoms associated.
Rationale: This action is Gastro Intestinal symptoms can show the effects of anemia (hypoxia) in the organ.
6. Collaboration for referral to a dietitian.
Rationale: This action is necessary help in planning a diet that meets the nutritional needs of the client.
II. Risk for Infection related to decreased body systems (main defense is inadequate), invasive procedures.
Nursing Intervention:
1. Monitor the trend of increase in body temperature.
Rational: that the fever caused by endotoxin effects on the hypothalamus and hypothermia are important signs that reflect the status of the development of shock / decrease in tissue perfusion.
2. Observe the chills and diaphoresis.
Rational: chills often precedes temperature peaks that occur in the general infection.
3. Monitor signs of deviation conditions / failure to improve during therapy.
Rational: may indicate inaccuracy antibiotic therapy or growth of the organism.
4. Give anti-infective drugs as directed.
Rational: could root out / give temporary immunity to common infections.
5. Get blood sample.
Rational: for identifying the causes of malaria infections.
III. Hyperthermia related to dehydration increased metabolism, direct effects of circulating germs in the hypothalamus.
Nursing Intervention:
1. Monitor the patient's temperature (degrees and patterns), note the chills.
Rational: hyperthermia showed an acute infectious disease process. Pattern suggests the diagnosis of malaria fever.
2. Monitor the temperature of the environment.
Rational: indoor temperature / number of blankets to be changed to maintain near-normal temperatures.
3. Give warm compresses bath, avoid the use of alcohol.
Rational: to help reduce the fever, the use of ice / alcohol may cause freezing. Addition of alcohol can also cause dry skin.
4. Give antipyretic drugs.
Rational: is used to reduce fever with central action on the hypothalamus.
5. Give a cooling blanket.
Rationale: This blanket is used to reduce fever with hyperthermia.
IV. Ineffective Tissue perfusion related to a decrease in the cellular components needed for the delivery of oxygen and nutrients in the body.
Nursing Intervention:
1. Maintain bed rest to help with maintenance activities.
Rational: reduce myocardial workload and oxygen consumption, maximizing the effectiveness of tissue perfusion.
2. Monitor the blood pressure trend, noting the development of hypotension and changes in pulse pressure.
Rational: hypotension will develop along with the germs that invade the blood.
3. Monitor the quality, the strength of peripheral pulses.
Rational: at the beginning of a strong rapid pulse due to an increase in cardiac output, pulse weak or slow due to ongoing hypotension, decreased cardiac output and peripheral vaso constriction.
4. Assess respiratory rate and depth of quality. Note the severe dyspnea.
Rationale: increased respiration occurs in response to the direct effects of the bacteria on the respiratory center. Breathing becomes shallow in the event of respiratory insufficiency, raises the risk of acute respiratory failure.
5. Give parenteral fluids.
Rational: to maintain tissue perfusion, a large amount of fluid may be required to support the circulation volume.
V. Deficient Knowledge: about the disease, prognosis and treatment needs related to lack of exposure / recall errors of interpretation of information, cognitive limitations.
Nursing Intervention:
1. Review the disease process and future expectations.
Rational: provides basic knowledge of where the patient can make a choice.
2. Provide information on the administration of drugs, drug interactions, side effects, and adherence to the program.
Rational: to increase understanding and enhance cooperation in healing and reducing recurrence of complications.
3. Discuss the need for proper nutritional intake and balanced.
Rationale: The need for optimal healing and general wellbeing.
4. Encourage periods of rest and activity scheduled.
Rational: energy savings and improve healing.
5. Review the need for personal hygiene and environmental cleanliness.
Rationale: Exposure control helps the environment by reducing the amount of the existing causes of disease.
6. Identify the signs and symptoms that require medical evaluation.
Rational: early recognition of progression / recurrence of infection.
7. Emphasize the importance of antibiotic treatment as needed.
Rational: the use of the prevention of infection.
