Ineffective Airway Clearance and Imbalanced Nutrition related to Measles

Measles is a medical condition characterized by the appearance of symptoms that resemble the flu, pink eye and a set of red rash. Accompanying symptoms include spots on the move seen in the mouth, which are characteristic of measles. This condition is more common in younger than 2 years of age and is very contagious, but are relatively rare due to the spread of vaccination programs throughout the world. The prognosis is generally good with a decent safety figures, but the overall cause complications, ranging from somewhat mild (such as diarrhea) to very serious (such as acute encephalitis); generally a complication that occurs in adults is more severe, such as malnutrition and immunodeficiency. Because the disease is highly contagious, the patient should immediately consult with a medical expert.

1. Ineffective airway clearance r / t increased production of secretions.

Expected results :

• Maintain the patient's airway with breath sounds clean or clear.
• Demonstrate behaviors to improve airway clearance, eg effective cough and remove secretions.

Intervention :
1. Auscultation of breath
Rational : some degree of bronchial spasma occur with airway obstruction.

2. Assess or monitor respiratory frequency
Rationale : tachypnea usually exist in some degree and can be found at the reception or during stress or the presence of an acute infectious process.

3. Note the presence or degree of breathlessness dipsnea
Rationale : Respiratory dysfunction is variable depending on the stage of a chronic process other than the processes that lead to acute hospital care.

4. Maintain a minimum environmental pollution, for example ; dust, smoke, and feather pillows are associated with individual conditions.
Rational : the originator of respiratory allergic type reactions can be acute episodes.

5. Observation of the characteristic cough
Rational : cough may persist but are not effective, especially if the patient is elderly, acute pain, or weakness. Cough most effective at high seating position or head down after percussion.



2 . Imbalanced Nutrition , Less Than Body Requirements r / t failure or inability to digest digest food or absorption of necessary nutrients .

Expected results :

• Showed an increase in body weight or body weight stable with normal laboratory values ​​.
• Not had signs of malnutrition .
• Demonstrate behaviors , lifestyle changes to improve and or maintain an appropriate body weight .

Intervention :
1 . Assess nutritional history , including the preferred food .
Rationale : identifying deficiencies , suspect the possibility of intervention .

2 . Observe and record the patient's food intake .
Rationale : overseeing the caloric intake or deficient quality of food consumption .

3 . Measure body weight per day
Rationale : evaluating the effectiveness of weight loss or nutritional interventions .

4 . Give a little bit of food and frequency often or eat between meals .
Rationale : eat little to reducing the vulnerability and increasing the intake also prevents gastric distension .

5 . Observe and record the incidence of nausea or vomiting , flatus , and other related symptoms .
Rationale : Gastrointestinal symptoms may indicate the effect of anemia ( hypoxia ) in the organ .

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