1. Activity intolerance related to mandatory bed rest.
1) Provide assistance to meet their daily needs such as food, drink, change clothes and watch oral hygiene, hair, genetalia, and nails.
Rationale: To provide assistance to the client to avoid the onset of complications associated with the movement who violate program bedrest.
2) Involve the family in the fulfillment of ADL.
Rationale: Participation family is very important to facilitate the nursing process and prevent further complications.
3) Explain the purpose of bed rest to prevent complications and speed up the healing process.
Rationale: Rest decrease intestinal mobility also decreases the rate of metabolism and infection.
2. Risk for fluid volume deficit related to the intake is less, nausea, vomiting / excessive spending, diarrhea, body heat.
1) Monitor the status of hydration (moisture of mucous membranes, skin turgor, adequate pulse, blood pressure orthostatic) if needed.
Rationale: Changes in hydration status, mucous membranes, skin turgor describe the severity of dehydration.
2) Monitor vital signs
Rationale: Changes in vital signs to describe the general state of the client.
3) Monitor the input of food / liquid and count daily calorie intake.
Rationale: Provides guidelines to replace fluids.
4) Encourage the family to help patients eat.
Rationale: Family as the driving fluid needs of clients.
5) Collaborate with other medical team for IV fluid administration.
Rationale: Giving IV fluids to meet fluid needs.
3. Imbalanced Nutrition, Less Than Body Requirements
related to less intake due to nausea, vomiting, anorexia, or diarrhea due to excessive output.
1) Monitor the amount of nutrients and calories.
Rationale: Knowing the cause of the less intake so as to determine appropriate and effective intervention.
2) Monitor the weight loss.
Rational: Cleanliness nutrients can be known through increased weight 500 g / week.
3) Monitor the environment during the meal.
Rationale: A comfortable environment can reduce stress and more conducive to eating.
4) Monitor nausea and vomiting.
Rationale: Nausea and vomiting affect nutrition.
5) Involve the family in the client's nutritional needs.
Rationale: Increasing the role of the family in nutrition to accelerate the healing process.
6) Instruct the patient to enhance the protein and vitamin C.
Rationale: Protein and vitamin C to meet nutritional needs.
7) Provide food selected.
Rational: To assist in fulfilling the nutritional needs.
8) Collaboration with a nutritionist to determine the amount of calories and nutrients it needs patients.
Rationale: Helps in the healing process.
4. Acute pain related to inflammation of the small intestine.
1) Assess the level of pain, location, duration, intensity and characteristics of pain.
Rationale: Changes in the characteristics of the pain may indicate the spread of diseases / complications occur.
2) Review the factors that increase pain and decrease pain.
Rational: It can pinpoint the factors that trigger or aggravate (such as stress, food intolerance) or identify the occurrence of complications, as well as help in making the diagnosis and therapeutic needs.
3) Give warm compresses on the area of pain.
Rationale: For the pain disappeared.
4) Collaborate with other medical team in the delivery of analgesics.
Rational: Analgesic can help reduce pain.
5. Knowledge Deficit: conditions of disease, treatment and prognosis needs related to lack of information or inadequate information.
1) Assess the extent of knowledge of the client's family about his illness.
Rationale: Knowing the mother's knowledge about the disease typhoid fever.
2) Give health education about the disease and treatment of clients.
Rationale: In order for the client's mother found out about the disease typhoid fever, causes, signs and symptoms, as well as the care and treatment of typhoid fever.
3) Give the family an opportunity to ask if there is not yet understood.
Rationale: In order to understand more about the family disease.