Nursing Care Assessment
Based on the information Nelson (2000), the data could focus on assessment of nursing care, among others:
1. Focus data :
- Increased body temperature usually occur in the afternoon.
- A history of respiratory tract infection.
- Decreased blood pressure, increased pulse rate, respiration increases.
- Non-productive cough.
- Epistaxis.
- Abdominal pain.
- Arthralgia.
- Loss of appetite.
- Losing weight.
2. Specific manifestations:
Carditis:
- tachycardia
- cardiomegaly
- voice murmurs
- changes in heart sound
- ECG changes (PR lengthwise)
- precordial pain
- pericardial friction rub
- joint swelling, heat, redness, tenderness.
- spread on the knee joint, elbow, shoulder, arm.
Subcutaneous nodules:
- swelling of the skin, soft palpable.
- coming shortly, in general readily absorbed.
- found on the extensor surfaces of the joints
Chorea:
- irregular movements of the extremities, involuntary.
- involuntary facial expressions
- speech disorders
- emotional lability
- muscle weakness
- muscle tension when anxious, lost when the break.
- reddish macular common on the torso and palms.
- the macula can not be permanently relocates à
- the macula is non pruritus
Nursing Diagnosis for Rheumatic Fever in Children
1. Knowledge Deficit : parents / child related to treatment, the activity restriction, the risk of cardiac complications.
Goal: complications did not occur and parents understand the child's disease.
Interventions:
- Auscultation of heart sounds to detect changes in rhythm.
- Give antibiotics according to the program.
- Restriction of activity to the clinical manifestations of rheumatic fever does not exist, and provide rest periods.
- Provide play therapy is appropriate and does not make patients tired.
- Give knowledge on mother and child about the disease and treatment procedures.
2. Ineffective individual coping related to disease conditions.
Goal: child understands about treatment procedures and can be cooperative, individual kooping effective.
Interventions:
- Assess the desire to play according to the age and condition.
- Create a schedule of activity and rest.
- Teach for participation in activities of daily necessities.
- Teach children / parents do not realize that the movement is associated with chorea and temporary.
4. Pain related to polyartritis.
Goal: lost and diminished pain.
Expected outcomes: child can control pain and mild pain scale of 2-3.
Interventions:
- Assess pain scale (1-10).
- Giving analgeik, anti-inflammatory and antipyretic according to the program.
- Repositioning to reduce joint stress.
- Give warm and cold treatment on a sore joint.
- Teach technique of distraction / relaxation for example; relaxation techniques and fantasy.
5. Risk for injury related to streptococcal infection.
Goal injury did not occur.
Interventions:
- Monitor the temperature every 4 hours during treatment.
- Give antibiotics according to the program.
- See also in discharge planning.
- Rest patients of activities that can make you tired.