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Minggu, 26 Oktober 2014

Ventricular Septal Defects - 7 Nursing Diagnosis and Interventions

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Ventricular Septal Defects - 7 Nursing Diagnosis and Interventions


Nursing Care Plan for VSD in Children

1. Decreased Cardiac Output related to cardiac malformations.

Goal: to improve cardiac output.

Outcomes: signs of improvement in cardiac output.

Intervention:
  • Observe the quality and strength of the heartbeat, peripheral pulses, skin color and warmth.
  • Assess the degree of cyanosis (mucous membranes, clubbing).
  • Monitor signs of CHF (anxiety, tachycardia, tachipnea, shortness of breath, tired while drinking milk, periorbital edema, oliguria and hepatomegaly.
  • Collaboration for the provision of drugs as indicated.


2. Impaired gas exchange related to pulmonary congestion.

Goal: improved gas exchange.

Outcomes: no signs of pulmonary vascular resistance.

Intervention:
  • Monitor the quality and rhythm of breathing.
  • Adjust the position of the child with Fowler position.
  • Avoid child of an infected person.
  • Give adequate rest.
  • Give oxygen as indicated.

3. Activity intolerance related to imbalance between oxygen consumption by the body and oxygen supply to the cells.

Goal: client activity are met.

Outcomes: Children participate in activities according to ability.

Intervention:
  • Allow the child frequent breaks and avoid disturbances during sleep.
  • Suggest to do the game and light activity.
  • Help children to choose activities appropriate to the age, condition and capacity of the child.
  • Give the period of rest after activity.
  • Avoid the ambient temperature is too hot or cold.
  • Avoid things that cause fear / anxiety child.

4. Delayed Growth and Development related to an inadequate supply of oxygen and nutrients to tissues.

Goal: There is no change of growth and development.

Outcomes: Growth of children according to the growth curves of weight and height.

Intervention:
  • Provide a balanced diet, high nutrients to achieve adequate growth.
  • Monitor height and weight.
  • Involve the family in providing nutrition to children.


5. Imbalanced Nutrition: less than body requirements related to fatigue at mealtime and increased caloric needs.

Goal: nutritional needs are met.

Outcomes: The child maintains food and beverage intake.

Intervention:
  • Measure body weight each day with the same scales.
  • Record intake and output correctly.
  • Give small portions of food frequently.
  • Give drink that much.

6. Risk for infection related to declining health status.

Goal: avoid infection.

Outcomes: no signs of infection.

Intervention:
  • Monitor vital signs.
  • Avoid contact with infected individuals.
  • Give adequate rest.
  • Provide optimal nutritional needs.

7. Parental Role Conflict related to hospitalization of children, fears of the disease.

Goal: There is a change in the role of parents.

Outcomes:
  • Parents express their feelings.
  • Parents are sure to have an important role in the success of the treatment.
Intervention:
  • The motivation of parents to express their feelings in relation to the child.
  • Discuss with parents about the treatment plan.
  • Provide clear and accurate information.
  • Involve parents in the care of the child while in hospital.
  • The motivation to involve families in the care of other family members of children.

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