1. Deficient Fluid volume: less than body requirements related to excessive fluid output.
Intervention:
- Observation of vital signs.
- Observed signs of dehydration.
- Measure the input and output of fluid (fluid balance).
- Provide and encourage families to give drink plenty of approximately 2000 - 2500 cc per day.
- Collaboration with physicians in the delivery of fluid therapy, electrolyte laboratory examination.
- Collaboration with a team of nutrition in low-sodium fluid administration.
2. Risk for Deficient fluid volume related to insufficient fluid intake, excessive discharge (vomiting / nausea).
Intervention:
- Record the number of vomiting and bleeding characteristics.
- Assess vital signs (BP, pulse, temperature).
- Monitor fluid intake and output.
- Elevate the head for taking medication.
- Give saturated liquid / soft if the input starts again, avoid caffeinated and carbonated beverages.
- Maintain bed rest.
- Collaboration with fluid administration as indicated.
3. Risk for ineffective airway clearance related to the operative incision site.
Intervention:
- Give analgesics as prescribed.
- Fixation incision with both hands or a pillow to help patients when they cough.
- Encourage the use of Incentive spirometer if there is an indication.
- Help and encourage early ambulation.
- Help the patient to change positions frequently.
4. Disturbed Body Image related to changes in appearance secondary to loss of body parts.
Intervention:
- Encourage the patient to express feelings, especially about the thoughts, feelings, views of self. Rational: Helping patients to be aware of unusual feelings.
- Note withdrawing behavior. Increased dependency, manipulation or not involved in treatment. Rational: Alleged problems in assessment can require follow-up evaluation and more rigorous therapy.
- Maintain a positive approach during maintenance activities. Rational: Help the patient / person closest to accept changes in their own bodies and feel good about themselves.