Chronic Pain, Impaired Physical Mobility and Disturbed Body Image r/t Scoliosis

Nursing Diagnosis and Interventions for Scoliosis

Scoliosis is a medical condition in which a person's spinal axis has a three-dimensional deviation. Although it is a complex three-dimensional condition, on an X-ray, viewed from the rear, the spine of an individual with scoliosis can resemble an "S" or a "C", rather than a straight line. Scoliosis is typically classified as either congenital (caused by vertebral anomalies present at birth), idiopathic (cause unknown, sub-classified as infantile, juvenile, adolescent, or adult, according to when onset occurred), or secondary to a primary condition.


Chronic Pain : back related to body position tilted laterally.

Goal: Pain is reduced or lost.

Interventions:

1. Assess the type, intensity and location of pain.
R /: Helpful in evaluating the pain, define the intervention options, specify the effectiveness of the therapy.

2. Adjust the position that increases the sense of comfort.
R /: Reduce muscle tension and coping adequately.

3. Maintain a quiet environment.
R /: Increase sense of comfort.

4. Teach relaxation and distraction techniques.
R /: To divert attention, thus reducing pain.

5. Encourage postural exercises regularly.
R /: With posturan exercise regularly speed up the process to fix the position of the body.

6. Collaboration: providing analgesic.
R /: To meredahkan pain.


Impaired Physical Mobility related to unbalanced posture.

Goal: Improve the physical mobility.

Interventions:

1. Assess the level of physical mobility.
R /: Influencing choice / monitoring the effectiveness of the intervention.

2. Increase activity if the pain is reduced.
R /: Provide an opportunity to expend energy.

3. Help and teach active joint range of motion exercises.
R /: Increase muscle strength and circulation.

4. Involve the family in performing self-care.
R /: Family cooperative can provide comfort to the patient.


Disturbed Body Image related to posture tilted laterally.

Goal: body image disturbance is resolved.

Interventions:

1. Encourage to express feelings and problems.
R /: Assist in ensuring trouble to start the troubleshooting process.

2. Give an open environment or supporting the patient.
R /: Increase the statement of beliefs / values ​​about positive subjects and identify misconceptions / myths that can affect the assessment of the situation.

3. Discuss the patient's perception about themselves and their relationship to change and how the patient sees himself in the pattern / role functioning normally.
R /: to help define the problem in relation to the previous pattern of life and assist in problem solving.

4. Encourage / provide visits by people who suffer from scoliosis, especially those that have succeeded in rehabilitation.
R /: Friends who have gone through the same experience, acting as role models and can provide validity statement and also hope for recovery and a normal.

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Newborn Priority Nursing Diagnosis and Intervention

Nursing Priority

• Facilitate adaptation to life outside the uterus.
• Maintain thermo-neutrality.
• Prevent complications.
• Increase parent-child closeness.
• Provide information and anticipatory guidance to parents.

Home Goals:

• Newborns effectively adapt to life outside the uterus.
• Free of complications.
• Parent-child closeness done.
• Parents express confidence in infant care.

Nursing Diagnosis for Newborn

First Hours of Life (Marilynn E. Doenges and Mary Frances Moorhouse, 2001 in the Maternal Infant Care Plan, p. 558-566)

1. Risk for Impaired gas exchange
related to antepartum stress, excessive mucus production, and stress due to cold.

Goal:
Free from signs of respiratory distress.

Interventions :

• Measure the Apgar score in the first minute and five minutes after birth.
• Note the prenatal complications that affect the status of the placenta and / or fetal (ie., Heart or kidney disorders, hypertension due to pregnancy, or diabetes).
• Clear the airway; nasopharyngeal suction slowly, as needed. Monitor the apical pulse during suctioning.
• Dry the baby with a warm blanket, place stockings head cover, and place it in the arms of parents.
• Put the baby in a modified Trendelenburg position at an angle of 10 degrees.

Rationale :

• Help determine the need for immediate intervention (ie., Suction, oxygen). Total score from 0 to 3 showed severe asphyxia or possibility to control neurological dysfunction and / or chemically with breathing. Scores 4 to 6 aggravate the difficulty adapting to extrauterine life. Score 7 to 10 indicates no trouble adapting to extrauterine life.
• This complication can lead to chronic hypoxia and acidosis, increasing the risk of damage to the central nervous system and require repair after birth.
• Helps eliminate accumulation of fluid, facilitates breathing efforts, and help prevent aspiration. Inhalation of oropharynx cause vagal stimulation that lead to bradycardia.
• Lowering effects of cold stress (ie., An increase in oxygen demand) and is associated with hypoxia, which can further depress respiration effort and lead to acidosis when the baby force with the end product of anaerobic metabolism of lactic acid.
• Facilitate the drainage of mucus from the nasopharynx and trachea with gravity.

2. Risk for Altered body temperature
related to inability to chills, body surface area in relation to the mass, the amount of subcutaneous fat finite, non-renewable sources of fat brown and some white fat deposits, thin epidermis with pooling of blood vessels close to the skin.

Goal:
Free signs of respiratory distress and cold stress.

Interventions :

• Note the presence of fetal distress or hypoxia.
• Dry the head and the body of a newborn baby, put the stockings headgear; and wrap in a warm blanket.
• Place the newborn in warm environments or at arm's parents. Warm objects that contact the baby (ie., Scales, stethoscopes, examination table and hands).
• Note the ambient temperature. Eliminate air flow and minimize the use of air conditioning; warm up when given oxygen through a mask.
• Assess the neonate's core temperature, skin temperature secar continuous monitoring with skin testing tool appropriately.

Rationale :

• Reduce heat loss due to evaporation and conduction, humidity protects the baby from the air flow or air conditioner, and limit the stress of displacement of the uterus warm environment to a cold environment (possibly 5 F [19 ° C] lower than the temperature of intrauterine) , (Note: Due to the relatively large area of a newborn baby's head in relation to the body, the baby can experience dramatic heat loss of moisture, the head is not closed).
• Prevent heat loss through conduction, in which heat is removed from the newborn to the object or surface that is cooler than the baby. Being held tightly near the body of parents of newborns and skin contact with the skin reduce heat loss in newborns.
• A decrease in ambient temperature 2 ° C (3.6 F) sufficient to indicate neonatal oxygen consumption. Heat loss through convection occurs when the baby loses heat to the cooler air flow. Lost via radiation occurs when heat is removed from the newborn to the object or surface that is not directly related to the newborn (ie., The walls of the incubator).
• Body temperature should be maintained closer to 36,5˚C (97,6˚F). Core temperature (rectal) usually 0,5˚C (0,9˚F) higher than skin temperature, but the continuous displacement of the core to the skin occurs so that the difference between the core and skin temperature is greater, the faster removal is becoming increasingly rapid temperature cool.

3. Altered family processes
related to transition the development and / or additional family members.

Goal:
Precisely identify the baby to ensure the correct family relationships.

Interventions :

• Inform parents about the needs of the newborn soon and care given.
• Place the baby in arm mother / father, as soon as conditions allow the newborn.
• Encourage parents to caress and talk to the newborn; encourage mothers to breastfeed if desired.

Rationale :

• Eliminate the anxiety of parents with regard to their baby's condition. Help parents understand the rationale for intervention in the period from the beginning of the newborn.
• The first hour of the baby's life is the most special meaning for family interaction which can increase the initial closeness between parent and baby and the acceptance of newborns as a new family member.
• Provide an opportunity for parents and newborns start the process of recognition and proximity.

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Nursing Care Plan for Hyperbilirubinemia in Infants

Hyperbilirubinemia is a condition where excessive concentration of bilirubin in the blood, causing joundice in neonates (Dorothy R. Marlon, 1998)



1. Impaired Skin Integrity related to jaundice or radiation.

Goal: good skin integrity / normal.

Expected outcomes:

• Good skin integrity could be maintained.
• No injuries / lesions on the skin.
• Good tissue perfusion.
• Protect the skin and retain moisture and natural treatments.

Intervention:

• Avoid wrinkles in the bed.
• Keep your skin to stay clean and dry.
• Mobilization of the patient every 2 hours.
• Monitor the existence of skin redness.
• Wash with soap and warm water.

2. Hyperthermia related to exposure to a hot environment.

Goal: temperature in the normal range.

Expected outcomes:

• Body temperature within normal range.
• Pulse and respiration within normal limits.
• There is no change in skin color.

Intervention:

• Monitor the temperature as much as possible.
• Monitor skin color.
• Monitor blood pressure, pulse, and respiration.
• Monitor intake and output.

3. Fluid volume deficit related to inadequate fluid intake, phototherapy, and diarrhea.

Goal: adequate body fluids.

Expected outcomes:

• Adequate fluid.

Intervention:

• Record the number and quality of feces.
• Monitor the skin turgor.
• Monitor intake output.
• Give water between breastfeeding or giving a bottle.

4. Knowledge Deficit related to the limitations of exposure.

Goal: family got knowledge about the disease that affects children.

Expected outcomes:

• The family said the understanding of the disease, condition, prognosis and treatment programs.
• Families are able to carry out the procedure described correctly.
• The family was able to explain again what is described nurse / other health team.

Iintervention:

• Describe the pathophysiology of the disease.
• Describe the signs and symptoms of the disease that usually appears in the right way.
• Describe the disease process in a proper way.
• Provide information on the patient's family about the conditions in an appropriate manner.

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Hypothermia in Newborn - Definition, Types and Symptoms

Definition of Hypothermia

Definition of hypothermia in newborns According to the Practical Handbook for Maternal and Neonatal Health Care (2002: M-122) "Hypothermia in newborns is a body temperature below 36.5 ° C measurement is made in the armpit for 3-5 minutes ".

Hypothermia baby is a baby's body temperature below normal (less than 36.5 0C). Hypothermia is one of the most common cause of death of the newborn, especially weighing less than 2.5 Kg.

Hypothermia can cause hypoglycemia (low blood sugar levels), metabolic acidosis (high blood acidity) and death. Because the body quickly uses energy to keep warm, so that when the baby cold requires more oxygen. Therefore, hypothermia can lead to reduced flow of oxygen to the tissues.


Types of Hypothermia

Several types of hypothermia, namely:

1. Accidental hypothermia occurs when core body temperature dropped to less than 35 ° C.
2. Primary accidental hypothermia is a result of direct exposure to cold air, and previously healthy.
3. Secondary accidental hypothermia is a complication of systemic disorders (whole body) are serious. Most occurrence in winter (snow) and cold climate.

Symptoms of Hypothermia

1. Baby's feet and hands felt colder than the chest.
2. Reduced activity.
3. Weak sucking ability.
4. Weak cries.
5. Fingers and feet bluish.

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