INTERVENTION

INTERVENTION

1. High risk of nutrition trouble : less than requirement relates to degradation of oral air mechanism input, anorexia, nausea, improvement of protein metabolism, fat.
Purpose : requirement of nutrition of patient fufilled
Result Criterion :
Patient can digest number of correct calories or nutrient
Stable body weight or addition towards spread usually
Intervention :
Deliberates body weight every day or as according to indication.
Determines diet program and pattern eats patient and compares to expendable food of patient.
Auskultasi intestine noise, log existence of flatulent abdomen pain in bone / stomach, nausea, food puking which has not have time to be digested, maintains situation of fasting as according to indication.

Gives nourishing liquid food ( nutrient) and electrolyte immediately if patient had its(the tolerance can passed oral air mechanism.
Entangles patient family at digestion eats this as according to indication.
observation of Marking hipoglikemia like change of level of awareness, skin lembab/dingin, pulse quickly, peckish, excitability, worries, headache.
Kolaborasi does inspection of blood sugar.
Kolaborasi therapy giving of insulin.
Kolaborasi craftily diet.

2. Insuffiency of dilution volume relates to diuresis osmotik.
Purpose : requirement of dilution or hydration of patient fufilled
Result Criterion :
Patient shows hydration which adekuat proved by stable vital sign, nadi perifer can be groped, skin turgor and admission filling of good capillary, haluaran acurate urine individually and electrolyte rate in normal boundary.
Intervention :
Vital marking watcher, log existence of change of ortostatic TD
Breath pattern watcher like existence of exhalation kusmaul
Frequency study and quality of exhalation, usage of muscle assists breath
Study nadi perifer, capillary admission filling, skin turgor and mucosa membrane
Input watcher and expenditure
Maintains to give [at] least dilution 2500 ml/hari in boundary which can be tolerance heart
Things log like nausea, puking and distensi [by] stomach.
Observation existence of increasing fatigue, oedema, improvement BB, nadi is not regular
Kolaborasi : gives normal dilution therapy copied with or without dextrosa, inspection watcher of laboratory ( Ht, BUN, Sodium, K)

3. Skin integrity trouble relates to change of status metabolik ( neurophathy perifer).
Purpose : skin integrity trouble can decrease or shows healing.
Result Criterion :
Condition of hurt shows existence of repair of network and is not infection
Intervention :
Hurt study, existence of epitelisation, discoloration, oedema, and discharge, frequency changes wraping.
Vital sign study
Study existence of pain in bone
Does treatment of hurt
Kolaborasi giving of insulin and medikasi.
Kolaborasi antibiotic giving according to indication.

4. Risk happened injury to relate to degradation function of eyesight
Purpose : patient doesn't experience injury
Result Criterion : patient can fulfill its(the requirement without experiencing injury
Intervention :
Obviates slippery floor.
Applies bed which low.
Orientates client with room.
Assists client in doing everyday activity
Assists ambulation impatient or position change