Fever

REPORT INTRODUCTION

Febrile / FEVER

A. Understanding Fever
A fever means the body temperature above the normal limit of normal, can be caused by abnormalities in the brain itself or by toxic substances that affect the central temperature regulation, bacterial diseases, brain tumor or dehydration. (Guyton, 1990).
Fever is a situation where an increase in temperature up to 380 C or more. There is also a restriction that take more than 37.80 C. Meanwhile, when the body temperature of more than 400C is called a high fever (hyperpyrexia). (Julia, 2000)


B. Etiology of Fever
Fever occurs when spending exceeds heat formation. Fever may be associated with infections, collagen diseases, malignancies, metabolic diseases and other illnesses. (Julia, 2000). According to Guyton (1990) fever can be caused by abnormalities in the brain itself or toxic substances that affect the central temperature regulation, bacterial diseases, brain tumor or dehydration.

C. Clinical Manifestations
Signs and symptoms of fever include:
1. Child's fussy (temperature higher than 37.8 C - 40 C)
2. Skin redness
3. Warm to the touch
4. Increased frequency of respiratory
5. Shiver
6. Dehydration
7. Loss of appetite

D. Pathophysiology of Fever
Fever occurs as the body's response to an increase in the set point, but there is an increase in body temperature due to the formation of excessive heat but is not accompanied by an increase in the set point. (Julia, 2000)
Fever is the body's defense mechanism (immune response) or zatasing children against infections that enter the body. If there is an infection or foreign substance into the body would stimulate the immune system to release pyrogen. Pyrogens are fever-causing substances, there are coming from inside the body (endogenous pyrogens) and outside the body (exogenous pyrogens) that can be derived from infection by microorganisms or an immunologic reaction to a foreign body (non-infectious).
The next pyrogens carry messages through the receiver (receptors) found on the body to be delivered to the center of the hypothalamic thermostat. In this pyrogen hypothalamus gets stimulated release of arachidonic acid and the resulting increase in the production of prostaglandins (PGEZ). This will raise the reaction temperature by means of peripheral blood vessels constrict and inhibit the secretion of the sweat glands. Hot expenditure decreased, there was an imbalance of formation and heat expenses.
This is the cause of fever in children. High temperatures will stimulate the activity of "soldiers" of the body (macrophages and T lymphocytes) to fight foreign substances by increasing proteolysis resulting in an amino acid that plays a role in the formation of antibodies or immune system. (Sinarty, 2003)
While the properties of chills or fever may be a crisis / flush.
Chills. When setting the thermostat to a sudden change from the normal level to a value that is higher than normal as a result of tissue damage, pyrogen substance or dehydration. Body temperature usually takes a few hours to reach the new temperature.
Crisis / flush. When the factors causing high temperatures to suddenly removed, the hypothalamic thermostat suddenly are at a low value, perhaps even return to normal levels. (Guyton, 1999)

E. Patways
Attached.

F. Management of Fever
1. In Physical
a. Keep an eye on the client's condition: Temperature measurement at regular intervals every 4-6 hours. Consider whether the child restless sleep, are often surprised, or delirium. Note also whether the child's eyes tend to glance up or if the child has a seizure. Fever accompanied by seizures that are too long can be harmful to the developing brain, because oxygen can not reach the brain. Cut off the supply of oxygen to the brain will result in the destruction of brain cells. In such circumstances, a lifelong disability can occur in the form of damage to certain intellectual functions.
b. Open excessive clothing and blankets
c. Taking into account the air flow in the room
d. Airway should be opened to prevent a loss of oxygen supply to the brain which will cause damage to cells - brain cells.
e. Give fluids by mouth, drink as much as possible
Drinks can be given water, milk (child diarrhea adjust), juice tea or water. Their purpose is to make the body fluid that evaporates due to the increase in body temperature obtained instead.
f. Enough sleep so that your metabolism decreases
g. Apply with plain water on the forehead, armpits, groin. The goal is to lower the body temperature of the surface of the child's body. The fall in body temperature on the surface of the body may occur due to body heat is used to evaporate water on the cloth compresses. Do not use ice water because it will make the blood vessels constrict and the heat can not get out. Using alcohol can cause irritation and intoxication (poisoning).
h. Currently, commonly used with warm compresses is lukewarm. Compress warm water or lukewarm then the outside temperature was warm and the body will interpret the outside temperature is hot enough. Thus, the body will lose control of the thermostat in the brain that control body temperature does not increase anymore. In addition, beyond a warm environment will make the blood vessels in the skin edges dilated or having vasodilatation, will also make the skin pores open so that will make it easier to heat emitting from the body.
2. Drugs Antipyretics
Centrally acting antipyretic lower the temperature in the temperature control center in the hypothalamus. Antipyretic useful to prevent the formation of prostaglandins by inhibiting the enzyme cyclooxygenase hypothalamic set point so that the degraded back to normal which ruled produce heat above normal heat and reduce spending no more.
Hint antipyretic administration:
a. Infants 6-12 months: ½ - 1 teaspoon of syrup paracetamol
b. Children 1-6 years: ¼ - ½ paracetamol 500 mg or 1-1 ½ teaspoon of syrup paracetamol
c. Children 6-12 years: 1 ½ tablets of paracetamol 5oo mg or 2 tablespoons of the syrup paracetamol.
Paracetamol tablets can be crushed and diluted with water or sweet tea. Febrifuge in given 3 times daily. Use a spoon to measure drug dose 5 ml each spoon.

G. Nursing Theory
Fever is very risky, the patient needs to be hospitalized, while nursing the patient to be considered is the risk of increased body temperature, fluid and electrolyte balance disorders, lack of parental knowledge about the disease.
a. The risk of increased body temperature
Often occurs when the body's metabolism increases, the need to be given anti pyretic to do a warm compress when the body temperature less than 37 C but when the heat more than 38oC are given extra pamol with given cold compresses.
b. Disorders of fluid and electrolyte balance
Common in children also experience anorexia as well as fever, fatigue, dizziness so that this situation led to a lack of nutrient inputs which then facilitates the onset of complications that need to be done with a liquid infusion of glucose and NaCl and the provision of supplementary food and soft foods that are easy to digest such as soft porridge.
c. Lack of parental knowledge about the disease
Be given counseling to families about how to cope if the child has seizures and fever that children avoid injuries and reduce panic parents. Besides, it also explain about the disease and its dangers.

H. Examination Support
Attached.

REFERENCES
1. Betz, Sowden. (2002). Pediatric Nursing Handbook, 2nd Edition. Jakarta, EGC.
2. Engel, Joyce. (1998). Pediatric Assessment. Ed. 2. Jakarta, EGC
3. Guyton, Arthur C. (1990). Human physiology danmekanisme disease. Ed. 3. Jakarta, EGC.
4. Guyton, Arthur C. (1997). Textbook of Medical Physiology. Ed. 9. Jakarta, EGC.
5. Ngastiyah. (1997). Sick Child Care, 2nd Edition. Jakarta, EGC.
6. Julia Klaartje Sometimes, SpA (2000). Right Methods to Overcome Fever. www. Google. Com
7. Sinarty hartanto. (2003). Fever Children Need Apply. www. Pediatrics. Com / knal.php
8. Sophia Theophilus. (2003). What to Look For When Child Fever.

NURSING CARE CHILDREN WITH DIARRHEA

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A. Definition
Some understanding of diarrhea:
1. Diarrhea is a bowel movement (defecation) with fecal liquid or semi-liquid, thus the water content in the stools more than normal bowel movements once the 100-200 ml (Hendarwanto, 1999).
2. According to WHO (1980) are diarrhea or loose stools liquid more than three times a day.
3. Diarrhea is a state frequency of bowel movements more than 4 times in infants and more than 3 times in a child with watery stool consistency, or green can be mixed with mucus and blood (Ngastiyah, 1997).
B. Cause
1. Factors infection
a. Enteral infection; gastrointestinal infections are a major cause of diarrhea, including infectious bacteria (Vibrio, E. coli, Salmonella, Shigella, Campylobacter, Yersinia, Aeromonas, etc.), viral infections (Enterovirus, Adenovirus, Rotavirus, Astrovirus, etc.), infection parasites (E. hystolytica, G.lamblia, T. hominis) and fungi (C. albicans).
b. Parenteral infection; an infection outside the digestive system that can cause diarrhea such as: acute otitis media, tonsillitis, bronchopneumonia, encephalitis, and so on.
2. Factors malabsorption
Carbohydrate malabsorption: disaccharides (lactose intolerance, maltose, and sucrose), monosaccharides (glucose intolerance, fructose and galactose). Lactose intolerance is an important cause of diarrhea in infants and children. In addition it is also possible malabsorption of fat and protein.
3. Food factor:
Diarrhea can occur by ingestion of spoiled food, toxic and allergic to certain foods.
4. Psychological Factors
Diarrhea can occur due to psychological factors (fear and anxiety).
C. Pathophysiology
The basic mechanisms that cause diarrhea are:
1. Impaired osmotic
The presence of food or substances that are not absorbed will cause the osmotic pressure in the intestinal lumen increases resulting in a shift in the water and elektroloit into the intestinal lumen. Fill cavity excessive bowel will stimulate the intestines to remove it causing diarrhea.
2. Impaired secretion
Due to certain stimuli (such as toxins) in the gut wall will increase the secretion of water and electrolytes into the lumen of the intestine and subsequent diarrhea arise because they increase the contents of the intestinal lumen.
3. Intestinal motility disorders
Hiperperistaltik will cause a reduction in the opportunity intestine to absorb food causing diarrhea. Conversely when intestinal peristalsis decreases will result in excessive growth of bacteria, subsequent diarrhea also can occur.
D. Clinical Manifestations
Acute diarrhea due to infection may be accompanied by vomiting, fever, tenesmus, hematoschezia, and abdominal pain or cramps. The most fatal consequence of diarrhea that lasts long without adequate rehydration is the cause of death due to dehydration or hypovolemic shock in the form of biochemical disorder continued metabolic acidosis. Seseoran a lack of fluids will feel thirst, weight loss, sunken eyes, dry tongue, cheek bones appear more prominent, decreased skin turgor, and the voice becomes hoarse. Complaints and symptoms are caused by the depletion of water isotonic.
Since the loss of bicarbonate (HCO3), the comparison with carbonic acid is reduced resulting in decreased blood pH stimulates the respiratory center so that the frequency increases and deeper breathing (Kussmaul breathing)
Cardiovascular problems at a later stage can be severe hypovolemic shock with signs of rapid pulse (> 120 x / min), blood pressure decreased to immeasurable. The patient became restless, pale face, cold akral and sometimes cyanosis. Due to a lack of potassium in acute diarrhea also can occur cardiac arrhythmias.
Drop in blood pressure will cause decreased renal perfusion to arise oliguria / anuria. If the condition is not immediately diatsi complications will arise acute renal tubular necrosis, which means a state of acute renal failure.
E. Management
Principles of Management
Management of acute diarrhea due to infection in adults consists of:
1. Rehydration therapy as a top priority.
2. Tata directed the work to identify the cause of the infection.
3. Provide symptomatic treatment
4. Provide definitive therapy.
ad.1. Rehydration therapy as a top priority.
There are 4 things to look for in order to deliver fast and accurate rehydration, namely:
1) Type of fluid to be used.
At this time Ringer lactate fluid is a liquid because it provides more choice in the market even though the amount of potassium low potassium levels when compared with feces. If RL is not available to diberiakn isotonic saline (0.9%), which should be supplemented with 1 ampoule Nabik 50 ml of 7.5% on every single liter of isotonic NaCl. In the initial state of mild acute diarrhea may be given fluids to prevent dehydration oralit with all its consequences.
2) The amount of fluid that was about to be given.
In principle, the amount of replacement fluids wish shall be proportionate to the amount of fluid out of the body. The amount of fluid loss from the body can be calculated in a way / formula:
- Measure BJ Plasma
Fluid requirements calculated by the formula:
BJ Plasma - 1.025
-------- X BB x 4 ml
0.001
- Methods Pierce
Based on the clinical situation, namely:
* Mild diarrhea, fluid needs = 5% x kg BW
* Moderate diarrhea, fluid requirement = 8% x kg BW
* Mild diarrhea, fluid requirement = 10% x kg BW
- Methods Daldiyono
Based on the clinical scoring as follows:
* Thirst / vomiting = 1
* 60-90 mmHg systolic BP = 1
* Systolic BP <60 mmHg = 2 * Frequency pulse> 120 x / min = 1
* Awareness of apathy = 1
* Awareness somnolence, sopor or coma = 2
* Frequency of breathing> 30 times / min = 1
* Facies Cholerica = 2
* Vox Cholerica = 2
* Decreased skin turgor = 1
* Washer women's hand = 1
* Extremities cold = 1
* Cyanosis = 2
* Age 50-60 years = 1
* Age> 60 years = 2
Fluid needs =
Score
--- X 10% x kg x 1 ltr
15th
3) The entrance or means of fluid
Route of administration of fluid in adults include oral and intravenous administration. Orali solution with a composition ranging from 29 g of glucose, 3.5 g NaCl, 2.5 g and 1.5 g KCl NaBik stiap liter is given orally in mild diarrhea as well as the first attempt after initial rehydration to maintain hydration.
4) Schedule of fluid
Initial rehydration schedule is calculated by BJ plasma or scoring system administered within 2 hours in order to achieve optimal rehydration as soon as possible. Fluid schedule for the second phase of the clock to-3 based on the loss of fluid 2 hours before the initial phase. Thus, rehydration is expected to complete by the end of the third hour.
2. Tata directed the work to identify the cause of the infection.
To determine the cause of the infection is usually associated with the clinical condition of diarrhea but the exact cause can be determined through examination of stool culture examination of urine accompanied by a full and complete stool.
Disorders of fluid balance, electrolyte and acid-base clarified through a complete blood count, blood gas analysis, electrolytes, urea, creatinine and plasma BJ.
When there is high fever and suspected systemic infection bile culture examination, Widal, malarial preparations and serological Helicobacter jejuni is highly recommended. Special examinations such as serology amoeba, fungi and Rotavirus usually follows after seeing the results of the filter.
Clinically acute diarrhea due to infection classified as follows:
1) Koleriform, diarrhea with fecal matter consists primarily of liquids only.
2) Disentriform, diarrhea with mucus mixed with feces and sometimes blood.
Investigations that have been mentioned above can be directed to appropriate manifestation klnis diarrhea.
3. Provide symptomatic treatment
Symptomatic therapy should really be considered losses and profits. Antimotilitas intestine as loperamide would worsen diarrhea caused by entero-invasive bacteria because the bacteria prolong the contact time with the intestinal epithelium should be rapidly eliminated.
4. Provide definitive therapy.
Causal therapy can be given to infection:
1) Cholera-eltor: tetracyclines or cotrimoxazole or chloramphenicol.
2) V. parahaemolyticus,
3) E. coli, do not need a specific therapy
4) C. perfringens, specific
5) A. aureus: Chloramphenicol
6) Salmonellosis: ampicillin or cotrimoxazole or quinolones such as Ciprofloxacin group
7) Shigellosis: Ampicillin or Chloramphenicol
8) Helicobacter: Erythromycin
9) Amebiasis: Metronidazole or Trinidazol or Secnidazol
10) giardiasis: quinacrine or Chloroquineitiform or Metronidazole
11) Balantidiasis: Tetracycline
12) Candidiasis: Mycostatin
13) Virus: symptomatic and supportive
G. The concept of Nursing
1. Assessment (Children Age 3 Years)
a. Main complaints: Discard the water several times with dilute consistency
b. Health History Now
In general, children entered hospital with complaints of waste liquid water many times either with or without vomiting, dpat feces and mucus or blood, other complaints that may be obtained are decreased appetite, increased body temperature, decreased volume diuresis and symptoms of impairment of consciousness
c. Past Medical History
Includes history assessment:
1) Prenatal
Keberapa pregnancy, date of birth, gestational (fulterm, premature, post-mature), abortion or the birth of life, health, long before / pregnancy, and medications were eaten and immunization.
2) Christmas
The duration of labor, place of birth, drugs, people who help labor, childbirth complications.
3) Post natal
Nomal weight 2.5 kg - 4 kg, normal body length of 49 -52 cm, good health, Apgar scores, or no congenital abnormalities.
4) Feeding
Breast milk or formula, weaning age (2 years), eating schedule / amount, the introduction of soft foods at 4-6 months, peubahan weight-gain, feeding problems (vomiting, colic, diarrhea), and the use of vitamins and minerals or other supplements.
5) previous Diseases
The causes, symptoms, disease, healing, kompliksi, the incidence of the disease in the family or community, emotional response to the previous hospitalization.
6) Allergies
Did you ever suffer from hay fever, asthma, eczema. Drugs, animals, plants, house dust
7) Medications obtained last
Name, dose, schedule, duration, reason for giving.
8) Immunization
Polio, hepatitis, BCG, DPT, measles, are complete at the age of 3 years, the reaction is usually fever, serum-serum granting another, gamma globulin / transfusion, giving tubrkulin test and reaction.
9) Growth
Weight at birth 2, 5 Kg - 4 Kg. Weight gain 150-200 g / week, increasing TB 2.5 cm / month, this increase occurred up to 6 months. Teeth begin to grow at the age of 6-7 months, start to sit alone at the age of 8-9 months, and can be up and running at the age of 10-12 months.
d. Psychosocial History
Children love toys, children are dependent on their parents and so hysterical when her parents separated. Minimum 3 years (toddlers) have learned to play with peers.
e. Spiritual History
Children already know a few things that are rituals such as praying.
f. Reaction Hospitalization
1. Separation anxiety: loss of family and community interaction are known, insecurity, anxiety and sadness
2. Changes in patterns of routine activities
3. Limited ability to communicate
4. Loss of autonomy
5. Fear of body integrity
6. Decreased mobility as an opportunity to learn about their world and the lack of opportunity to carry out his pleasure
g. Day-to-Day Activities
1. Fluid requirements at age 3 years was 110-120 ml / kg / day
2. Output fluid:
(A) IWL (Insensible Water Loss)
(1) Children: 30 cc / kg BW / 24 hours
(2) increased body temperature: 10 cc / Kg BB + 200 cc (body temperature - 36.8 ° C)
(B) SWL (Sensible Water Loss) is the loss of fluid that can be observed, for example in the form of urine and faeces. That is:
(1) Urine: 1-2 cc / kg BW / 24 hours
(2) Faeces: 100-200 cc / 24 hours
3. At the age of 3 years has taught toilet training.
h. Physical examination
a) Vital signs
Body temperature: an increase
Nadi: fast and weak
Respiratory: respiratory frequency increased
Blood pressure: decreased
b) Anthropometry
Anthropometric examination includes weight, height, circle head, arm circumference, and abdominal circumference. In children with diarrhea, weight loss.
c) Respiratory
Usually breathing rather fast, normal chest shape, and found no additional breath sounds.
d) cardiovascular
Usually there were no abnormalities, rapid and weak pulse.
e) Digestion
Found symptoms of nausea and vomiting, dry lips and mouth mucosa, increased intestinal peristalsis, anorexia, SECTION 3 x more watery consistency
f) urinal
Volume decreased diuresis.
g) Musculoskeletal
Physical weakness due to excessive output.
h) Integumentary
abrasions around the anus, the skin felt warm, ugly skin turgor
i) Endocrine
Not find any kelaianan.
A) Sensing
Sunken eyes, nose, ears no abnormalities
k) Reproduction
No abnormalities.
l) Neorologis
Impairment of consciousness can occur.
2. Level Examination Development
1) gross motor
It can go up / down stairs without assistance, mamakai clothes with help, can start cycling tricycle.
2) fine motor
Menggambat circle, washing hands and brushing teeth alone
3) Personal Social
've Learned to play with his peers.
4. Nursing Diagnosis
a. Lack of fluid volume excess bd loss through feces and vomiting, and limited intake (nausea).
b. Changes in nutrition less than body requirements bd impaired nutrient absorption and increased intestinal peristalsis.
c. Pain (acute) hiperperistaltik bd, irritation perirektal fissure.
d. Anxiety bd families change their child's health status
e. Lack of family knowledge about the condition, prognosis and therapy needs exposure bd limited information, false or interpretation of information and cognitive limitations.
f. Bd separation anxiety children with parents, new environmental
5. Nursing Plan
Lack of fluid volume Dx.1 b / d lost in faeces and vomit excessively and limited intake (nausea)
Objective: fluid requirements will be met with the criteria no signs of dehydration

Stimulation Example Child Development by Age

Developmental tasks throughout the life span by Havighust (Hurlock, 1994) such as infancy and early childhood include learning to eat solid food, learning to walk, learning to talk, learning to control the body's sewage, studying gender differences and of procedures , prepare to learn to read, learn to distinguish between right and wrong, and begin to develop a conscience. There is also the end of my childhood include learning physical skills necessary for the common games, build a healthy attitude about themselves as beings who are growing, learning to adjust to peers, began to develop a social platform right of men and women, develop basic skills for reading, writing and numeracy, develop notions needed for daily living, develops a conscience, moral sense, and good levels of value, develop attitudes toward social groups and institutions, achieve personal freedom.

Stimulation should be done every time there is a chance to interact with your baby or toddler, such as bathing, changing diapers, feeding, food feeding, holding, taking a walk, playing, watching TV, in the car, at bedtime.
Stimulation for infants 0-3 months by the way: seek a sense of comfortable, safe and fun, hugging, holding, baby eyes, inviting smile, talk, sounding alternately various sounds or music, hanging brightly colored and moving objects (circles or boxes black-and-white), sound objects, to overthrow the baby right-left, prone-supine, stimulated to reach out and hold toys.
Age 3-6 months plus play 'boo', saw the face of a baby and a nanny in the mirror, stimulated to his stomach, stretched back and forth, sat. Age 6-9 months plus by calling his name, asked shaking hands, clapping, reading fairy tales, stimulate sitting, standing holding trained. Age 9-12 months coupled with the repeated mention of mama-papa, brother, put toys into a container, drinking glass, roll the ball, trained to stand, walk with support. Age 12-18 months coupled with doodling exercises using colored pencils, arrange cubes, blocks, pieces of simple images (puzzle) insert and remove small objects from the container, playing with dolls, spoons, plates, cups, teapots, broom, rag. Practice walking without holding, walking backward, climb stairs, kick a ball, take off pants, understand and carry out simple commands (which a ball, hold it, enter it, grab it), the name or showing objects. Age 18-24 months plus by asking, mentioning and showing the parts of the body (where the eye? Nose?, Ears?, Mouth? Etc.), ask for a picture or mention the names of animals and objects around the house, talking about daily activities -day (eating, drinking bathing, playing, ask etc.), training drawing lines, wash their hands, wear pants - clothes, playing throw ball, jump. Age 2-3 years plus to know and mention the color, using adjectives (big-small, hot-cold, high-low, many-bit, etc.), the names of friends, counting objects, wear clothes , brushing teeth, playing cards, dolls, cooking-cooking, drawing lines, circles, man, practice standing on one leg, urination / big toilet.
After 3 years in addition to developing life skills before, stimulation was also directed to school readiness include: holding a pencil properly, write, recognize letters and numbers, simple math, understand simple commands (pee / big toilet), and independence (left at school), share with friends, etc.. Stimulation can be done at home (by caregivers and family) but could also be in play groups, kindergartens or the like (Soedjatmiko, 2011)