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NCP Hirschsprung's Disease : Assessment, Nursing Diagnosis and Interventions

Nursing Care Plan for Hirschsprung's Disease

Assessment of Hirschsprung's Disease

1. Activity / rest
  • Symptoms: Malaise, changing patterns of rest / sleep associated with pain, limitations.
2. Ego Integrity
  • Symptoms: Anxiety, fear, feelings of helplessness parents.
3. Elimination
  • Symptoms: Constipation can be accompanied by diarrhea.
  • Symptoms: Abdominal distension progressively, until the thin abdominal wall veins visible, peristaltic activity can be observed.
4. Food / fluid
  • Symptoms: Anorexia, nausea, vomiting, weight loss.
  • Signs: Decrease subcutan fat / muscle mass, weakness, a sign of malnutrition and growth failure.
5. Pain / comfort
  • Symptoms: Abdominal pain.
  • Signs: Facial expressions grimacing, moaning / crying, behavioral distraction, abdominal tenderness / distension.
6. Extension / learning
  • Parent questions related to the disease, care and treatment of children.
  • Patient's discharge plan: Requires assistance / demonstration how irrigation and colostomy care, the ability to assess the incidence of abdominal distension and obstruction.

Nursing Diagnosis and Interventions for Hirschsprung's Disease - Preoperative

1. Altered Bowel Elimination: observations related to hypertrophy and distention of the proximal colon.

Goal: Observation does not happen.

  • Clients say can defecate.
  • Normal intestinal peristalsis.

1 Assess the client's pattern of elimination.
R /: Identify custom client to facilitate further action.

2 Encourage clients to drink water from 1500 to 2000 cc / day.
R /: Adequate fluid intake can improve the balance between absorption in the colon and fluid intake, thereby preventing the formation of a hard feeces.

2. Imbalanced Nutrition: Less Than Body Requirements related to intake less.

Goal: Fulfillment of nutrients can be resolved.

  • Clients no nausea and vomiting.
  • Inkate adequate.
  • Clients are not weak.
1 Monitor food intake.
R /: Adequate intake affect the healing process.

2 Provision of adequate calories and balanced meals.
R /: Caloric intake helps the body to maintain homeostasis.

3 Encourage clients to spend a portion of their food.
R /: Adequate intake can assist in improving the general state of the client.

3. Anxiety related to ineffective coping.

Goal: Anxiety is resolved.
  • Cheerful facial expressions.
  • Clients and their families are not asked again about his illness.
  • Clients and their families have hope of recovery.
1 Assess the level of anxiety.
R /: Make it easy for the next action.

2 Give the opportunity to the clients and their families to express his feelings.
R /: Thus the client and his family was relieved to express feelings.

Nursing Diagnosis and Interventions for Hirschsprung's Disease - Postoperative

1. Acute Pain related to the continuity of body tissues.

Goal: The client expresses a sense of comfort pain reduced / lost.
  • Clients complained of pain at the surgical wound.
  • Cheerful facial expressions.
  • Vital signs within normal limits.
  • Relationships within normal limits.

1 Assess and record the location and duration of pain.
R /: Knowing the client's perception and reaction to pain as an effective basis for further intervention.

2 Give a fun position.
R /: Reduce emphasis on muscle and prevent muscle spasms that can cause pain.

3 Observation of vital signs every 2 hours.
R /: Practice deep breathing slowly and regularly will help to relax the muscles so that the supply of O2 to the tissue smoothly, thus reducing pain.

4 Implementation of appropriate analgesic drug administration programs.
R /: Analgesic serves to inhibit stimuli that are not perceived pain, so that pain is reduced / lost.

2. Disturbed Sleep Pattern related to postoperative wound pain.

Goal: Sleep patterns resolved.
  • Clients sleep 7-8 hours.
  • Clients seem cheerful.
1 Assess sleep patterns and intirahat clients.
R /: Knowing the disturbance of rest / sleep clients to determine further intervention.

2 Create a pleasant environment.
R /: A quiet environment can provide peace to rest and sleep.

3 Encourage clients to a lot of rest and enough sleep.
R /: Adequate sleep can give a fresh taste to the clients and accelerate the healing process.