According Doenges, et al (2000) in providing nursing care to clients with Typhoid Fever using the five stages of the nursing process, which includes: assessment, nursing diagnosis, planning, implementation and evaluation.
1. Assessment for Typhoid Fever
The initial steps of the nursing process is a systematic assessment, continuous, valid, and client data obtained from interviews and observations (Carol Taylor, 1997)
As for the things that need to be assessed on the client with typhoid Fever by Doenges, et al (2000: 481) is as follows:
a. Activity / rest
- fatigue malaise
- restrictions on activities / work until the effects of the disease process.
- tachycardia (in response to fever, dehydration, inflammation)
- blood pressure hypotension
- skin or mucous membranes: poor turgor, dry skin, dirty tongue, lips chapped.
c. Ego integrity
- anxiety, fear, emotional upset.
- stress factors
- rejected, narrowed attention, depression
- stool texture varies from hard to soft shape, even watery.
- bloody defecation
- rectal bleeding.
- if constipation then decreased bowel sounds do not even exist, but the bowel diarrhea will increase.
e. Food / fluid
- anorexia, nausea / vomiting
- weight loss
- dirty tongue
- decrease in subcutaneous fat / muscle mass
- weakness, muscle tone and poor skin turgor
- inability to maintain self-care
- body odor
g. Pain / Leisure
- pain / tenderness in the lower left quadrant.
- pain point moves, tenderness (arthritis).
- eye pain.
- abdominal tenderness / distension.
- increased body temperature 39 – 40oC.
- blurred vision.
- allergies to food or dairy products (histamine release into the gut and has the effect of inflammation).
- decreased frequency / avoid sexual activity.
j. Social interaction
- relationship problems / roles with respect to the condition.
- active in social incompetence.
- counseling / learning.
2. Nursing Diagnosis for Typhoid Fever
Nursing diagnosis is a statement that describes the human response (health status or risk of change in the pattern) of an individual or group in which nurses are able to identify and provide accountability for certain interventions to maintain health status, reduce, limit, prevent and change. (Nursalam, 2001: 52) quoted from (Carpenito, 2000)
Nursing diagnoses that often appears on the client with typhoid Fever is as follows:
a. Hyperthermia related to the process of infection
b. Constipation / Diarrhea related ton changes the planning process, decreased physical activity.
c. Imbalanced Nutrition: less than body requirements related to no appetite and nausea.
d. Risk for Deficient Fluid Volume related to loss through the normal route (diarrhea and vomiting).
e. Deficient Knowledge : about the condition, prognosis, and treatment needs related to misinterpretation of information, lack of recall.
(Doenges, et al, 2000; 471)
3. Nursing Interventions for Typhoid Fever
After formulating the nursing diagnosis, the next step is to determine the planning of nursing. Planning involves developing design strategies for preventing, reducing, and correcting the problems identified in the nursing diagnoses. This stage begins after determining nursing diagnoses and concluded the plan documentation.
(Nursalam, 2001: 51 quoted from the layer, taptich, and Bernocchi-Losey, 1996)
In the planning stages include: Determining priorities, determine outcomes, determine a plan of action and documentation. (Nursalam, 2001: 52)
The plan is based on each nursing diagnosis by Doenges, et al (2000) are:
A. Hyperthermia related to infectious process
Goal: Hyperthermia is reduced or lost
Expected Outcomes :
- body temperature within the normal range (36 – 370C).
- free from the cold
Plan of action:
1) Monitor the client’s temperature (degrees and patterns), note the chills / diaphoresis.
R: temperature 37.9 ° C or more indicates the infection process. Fever pattern may help in the diagnosis, such as typhoid, fever remittances (varies).
2) Monitor the temperature of the environment
R: The ambient temperature / number of blankets to be changed to maintain near-normal temperatures.
3) Provide warm compresses bath, avoid the use of alcohol.
R: Can help reduce fever. The use of alcohol may cause chills, increased temperature and can actually dry out the skin.
4) Collaboration with physicians for the provision of antipyretic
R: Used to reduce fever with central action on the hypothalamus.
Goal: The pattern of bowel movements back to normal
- Clients can defecate / frequency in the normal range (1 x / day).
- Soft stool consistency
- Back to normal intestinal peristalsis (5-15 x / min)
Plan of action:
1) Auscultation of bowel sounds
R: The sound of the gut in general increased in diarrhea and decreased in constipation.
2) Encourage fluid intake is 2500-3000 cc / day.
R: To assist in improving the consistency of the stool when constipated. Will help maintain hydration status on diarrhea.
3) Encourage gradual mobilization.
R: Loss of muscular tone will reduce intestinal peristalsis or can damage the rectal sphincter control.
4) Encourage foods with high fiber content, such as fruits (papaya) and pudding.
R: Improving stool consistency and stool spending.
5) Collaboration with physicians for drug delivery stool softeners: Suppositories moment when anticholinergic constipation and diarrhea.
C. Imbalanced Nutrition: less than body requirements related to no appetite and nausea.
Goal: Nutrition met.
- Experiencing weight gain or stable.
- There were no signs of malnutrition.
Plan of action:
1) Measure body weight every day when conditions allow.
R: Providing information about dietary needs / effectiveness of therapy.
2) Give the food a little and often.
R: Maximizing nutrient intake, to prevent nausea and reduce irritation of the stomach wall.
3) Avoid stimulating foods, such as spicy and sour and cold.
R: stimulating and cold food can cause nausea.
4) Perform oral hygiene
R: a clean mouth can increase the sense of eating
5) Explain the importance of nutrition for healing.
R: Knowledge increased so motivated to eat
6) Assess diet (diet clients in the home, food likes and dislikes)
R: Identify patterns that require change and as a basis for evaluating the diet program.
7) Encourage clients fibrous foods such as papaya, pudding and others.
R: Fiber resist digestive enzymes and absorbing water in the stream along the intestinal tract and thus can lead to bulk, which works as a stimulus for defecation.
8) Collaboration with physicians for antiemetic medication.
R: Antiemetika to prevent nausea and vomiting.
D. Risk for Deficient Fluid Volume related to loss through the normal route (diarrhea and vomiting).
Goal: lack of fluid volume did not happen
– Vital signs are within normal limits
– Intake and output balanced
– Consistency normal urine (1 cc / kg body weight / hour)
– Good skin turgor
Plan of action:
1) Assess vital signs
R: Hypotension, tachycardia and fever may indicate a response to fluid loss.
2) Observation of skin turgor
R: Indicates excessive fluid loss / dehydration.
3) Measure intake and output
R: Provide information as a guide for fluid replacement.
4) Collaboration with physicians for parenteral fluid administration.
R: To replace lost fluids.
E. Knowledge Deficit : about the condition, prognosis, and treatment needs related to misinterpretation of information, lack of recall.
Goal: Expressing its understanding of the conditions / processes and treatment of the disease.
Identifying the relationship between the signs / symptoms of the disease process and relationship with symptoms factor.
Pinpoint the necessary procedures and explain the reason for an action.
Initiate the necessary lifestyle changes and participate in treatment rules.
Plan of action:
1) Determine the patient’s perception challenge panyakit process.
R: Creating awareness and provide basic pengatahuan individual learning needs
2) Review the disease process, the cause or effect relationship factors that cause symptoms and identify ways to reduce the factors supporting
R: Knowledge of accurate base gives patients the opportunity to make an informed decision or choice about the future and control of chronic diseases.
3) Review the drug, purpose, frequency, dosage, and possible side effects
R: Improving understanding and to increase cooperation in the program
4) Emphasize the importance of skin care, such as good hand washing techniques and good perineal care.
R: Reduce the spread of bacteria and the risk of skin irritation or damage, infection.