Diagnosa Keperawatan, Perencanaan, dan Implementasi Mual berhubungan dengan berbagai penyebab causes Hasil yang diinginkan: pasien menyatakan mual dan muntah tidak ada 1.
reda, bebas bau lingkunga bersih sehingga tidak menyebabkan mual
2.
berikan anti emetic
3.
perawatan oral untuk mengurangi emesis dan meningkatkan kenyamanan
4.
menjelaskan kepada pasien untuk menjauhi penyebab atau makanan yang dapat
menyebabkan muntah Resiko aspirasi berhubungan dengan penunrunan gag reflek atau penuruanan kesadaran Hasil yang diinginkan: Jalan napas dan suara paru pasien bersih 1.
kaji apakah pasien dalam keadaan resiko untuk aspirasi
2.
tempatkan pasien dalam posisi yang dapat mencegah aspirasi .
Kekurangan Cairan Hasil yang diinginkan: tanda vital pasien dalam batas normal 1.
monitor adanya tanda hypovolemia untuk mencegah adanya komplikasi yang mungkin
terjadi 2.
timbang berat badan tiap hari
3.
monitor intake output dan tanda vital, dan tanda vital tekanan darah ortohstatik
4.
berikan cairan per IV
5.
monitoring pengeluaran cairan selama pengobatan untuk mencegah deficit dan
kelebihan cairan
Nursing care in patients with nausea and vomiting iklan1 Nursing care in patients with nausea and vomiting: " Nausea is the subjective feeling of wanting to throw up. Vomiti ng is the expenditure of gastric contents through the esophagus and mouth. Nausea and vomiting are the most experience felt by everyone. Vomiting is also the body's defense mechanism of hazardous materials from the digestive tract. Gag reflex is controlled by the vomiting center in the brain. The mechanism of vomiting is very complex. Many of the causes that can cause vomiting, namely:
1. 2. 3. 4. 5. 6. 7.
virus infection stress gestation drug myocardial infarction uremia other conditions
Therapeutic intervention
Nausea and vomiting are very few require intervention. However, if left unchecked will lead to dehydration and electrolyte imbalance. Loss of hydrochloric acid from the stomach can cause metabolic alkalosis. Vomiting black like kofi show vomit mixed with blood. Protection on Jalam breath for vomiting is the most important measures to prevent aspiration. Increased risk of aspiration in pati ents with decreased consciousness, the elderly, and the gag reflex failure. Align the patient in a comfortable position so that vomit out. Beating back when vomiting can lead to aspiration.
Nursing Process in Patients Nausea and Vomiting
Assessment / data collection
1. 2. 3. 4.
Episodes of nausea and vomiting Medical Conditions Drugs consumed treatment is being done
1. bingunng 2. oliguria 3. skin cool and moist 4. chest pain and abdominal
Nursing Diagnosis, Planning, and Implementation
Nausea associated with various causes of causes
The desired result: nausea and vomiting patients expressed no
subsided, odor-free environme clean so does not cause nausea provide anti-emetic oral care to reduce emesis and increased comfort explained to the patient to avoid foods that cause or may cause vomiting
Risk of aspiration associated with penunrunan gag reflex or penuruanan kesadara
The desired outcome: airway and lung sounds net patient
assess whether the patient is in risk for aspiration
place the patient in a position to prevent aspiration.
Lack Fluids
The desired result: the patient's vital signs within normal limits
monitor for signs of hypovolemia to prevent any complications that may occur weights every day intake and output monitor vital signs, blood pressure and vital signs ortohstatik give fluids by IV discharge monitoring during treatment to prevent deficit and excess fluid
