ncp with ds

8/8/2019 ncp with ds

1/11

ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATIONSubjective:

y H

indi pa siyaumiihi sa

araw na ito.

as

verbalized by

the mother

Objective:

y

Periorbitaland pedal

edema noted

y Irritable whenawake

y LOC: lethargicy UA: SG= 1.015y CBC: Hct =30%Hgb = 10.1y VS: BP =

130/90

Fluid volume

excess relatedto decreased

glomerular

filtration rate as

evidenced by

decreased urine

output,decreased Hgb

& Hct and

Hypertension

Short Term:

After 8 hours of

intervention, the

client will:

y Maintainfluid volume

at a

functional

level asevidenced by

stable vital

signs, ideal

body weight,

and

reduction of

edema.

Independent

Evaluate extent of fluid

excess:

y Assess vital signs:BP, PR, RR,

quality of pulse,

respiratory

effort.

y Note complaintsassociated withfluid excess:

edema, poor skin

turgor, distention

of neck veins,

sudden increase

in weight

y Obtain andevaluate labresults (Hct, Hgb,

Serum

electrolytes,

BUN/Creatinine,

total

protein/albumin)

Limit sodium and fluid

intake to prescribedvalue:

y Advise familymembers to

remove water,

food or drinks

from bedside.

y Identify potential

y Obtain baseline forcomparison.

Objectiveand subjective data

help identify

underlying cause and

monitor progress.

y Fluid restriction isbased on urine

output, weight and

response to therapy.

y To monitor othersources of excess fluid

y Understanding andcomfort promotes

compliance. Oral

hygiene minimizes

dryness of oral

mucosa.

y Prevent fluid overloadand address causative

factors.

After performing

interventions for 8

hours, the client:

y Had vitals nearnormal levels,

no longer

complains of

headaches,

and has visiblyreduced

periorbital

edema.

y Complied andactively

participated in

the

interventionspresented

y Verbalized thatwas willing to

comply with

health

teachings

provided as to

fluid anddietary

restrictions.


2/11

sources of fluid

(IV and oral

meds, food, etc),

and factor them

in when

determining fluid

intake.

Assist client and family

to cope with the

discomfort caused by

fluid restrictions:

y Explain therationale behind

fluid restriction.

y Encourage thefamily to provide

a supportive and

caring

atmosphere

y Provide and/orencourage

frequent oral

hygiene

Dependent

y Administer IVfluids and meds

as prescribed.


3/11

ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATIONy Subjective:y K

anina pa syamainit as

verbalized by

the mother

yy Objective:y VS: Temp=38.4

C

Imbalanced

bodytemperature

related to

unknown

etiology

(possibleinfection) as

evidenced by

Temp=38.4

C

Short Term:

After 4 hours of

intervention, the

client will:

y Maintainbodytemperatur

e at a

functional

level as

evidenced

by Temp


4/11

encourage

frequent oral

hygiene

y Assist client andfamily in planning

and performing

future self-care

needs:

y Demonstrateproper procedure

for TSB.

y Explain therationale behind

intervention

done

y Encourage thefamily to provide

a supportive and

caring

atmosphere

y Dependenty Administer IV

fluids and meds

as prescribed.

y


5/11

ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION

Objective:

- Low hgbcount (10.1)

- Low

hematocrit

count ( 30)

- Paleness

- PalePalpebral

conjunctiva

- Body

weakness

- Restlessn

ess

- Cold and

clammy skin

Ineffective

tissueperfusion

related to

decrease in

hemoglobin

count (10.1)

Short term:After 4 hrs of

nursing

interventions the

patient will be

able to verbalize

understanding ofcondition and

therapy regimen

- Establish rapport

- Monitor and record VS

-Assess pt. gen. condition

-Encourage quiet, restful

atmosphere

-Encourage early

ambulation once

tolerated

-Discourage

sitting/standing for long

periods, wearing

constrictive

clothing, crossing legs -

Check for calf

tenderness

- Elevate head of bed

especially at

night

-Instruct to avoid

strenuous activity

- Restrict sodium, fluid

and fat intake as

indicated

- Instruct patients SO

about food rich

in iron

-Regulate IVF As ordered

-Promote adequate bed

rest

- Attend needs

-Administer

meds as ordered

To gain trust and cooperation

-To have a

baseline data

-To have baseline data

and note any abnormal

findings

-To conserve energy/lower

tissue oxygen demands

-To enhance venous return

-To improve and facilitates

good Circulation

-May indicate thrombus

formation

-To increase gravitational

blood flow

-To conserve energy

-To decrease excess fluid

volume

-To increase hgb count

-To maintain hydration

-To promote wellness

-To promote health

-To promote recovery

The patient shall have

verbalized

understanding of

condition and therapy

regimenafter 4 hours

of

Nursing interventions


6/11


7/11

low-potassium,

high-calorie,

protein-

restricted butalbumin-rich

diet (graham

crackers, low-

salt crackers,

egg whites,

dairy products)

y Identify foodwithin theclients

preferences

but comply

with dietary

restrictions.

Provide a list.

y Advise familymembers toremove water,

food or drinks

from bedside.

1. Assist clientand family to

cope with the

discomfort

caused byrestrictions in

the diet:

y Explain therationale

behind dietary

restriction.

y Encourage the

y Makes diet morepalatable to theclient.

y To evaluateprogress and to

detect

complications

early

y Ensures continuityof care.


8/11

family to

provide a

supportive and

caringatmosphere

y Providealternatives for

improving diet

without

deviating from

the prescribedone.

1. Monitor andrecord clients

progress:

y Weigh patientdaily

y Assess for signsof inadequateprotein intake

(edema,

delayed

healing,

decreased

serum albumin

levels)

Collaborative

y Coordinatewith other

health care

personnel

(physician,

nutritionist).


9/11

Captopril (Capoten)

THERAPEUTICCLASS

ACTION CONTRAINDICATION TOXIC EFFECT/SIDEEFFECT

NURSING MANAGEMENT

Antihypertensive Thought to inhibit

ACE, preventing

conversion of

angiotensin I to

angiotensin II.Reduced formation

of angiotensin II

decreases

peripheral arterial

resistance, thus

decreasing

aldosterone

secretion.

Reduces Na

and water

retention, lowers

blood pressure andhelps improve renal

function adversely

affected by

diabetes.

Contraindicated in

patient

hypersensitive to

drug or other ACE

inhibitors. Use

cautiously in

patients with renal

impairment.

Renal

impairment,

urinary

frequency

"Instruct patient not to

abruptly discontinue use

of captopril without

notifying the health careprovider.

Rebound hypertension

may occur.

"Inform client not to take

OTC drugs (ex. Cold and

allergy medications)

without first contacting

the health care provider.


10/11

Furosemide (Lasix)

THERAPEUTIC CLASS ACTION CONTRAINDICATION TOXICEFFECT/SIDE

EFFECT

NURSING MANAGEMENT

Diuretic

Antihypertensive

Inhibits Na

and Cl

reabsorptio

n atproximal

and distal

tubules and

ascending

loop of

Henle.

Promotes

water and

Na

excretion.

Contraindicated

in patient

hypersensitive

to drug or any

of its

components

and in those

with anuria.

Headache,

restlessness,

weakness

>Check onset of action for

furosemide. The urine output should

increase in 5-20 mins. If urine

output does not increase, notify thehealth care provider.

severe renal disorder may be

present.

>Monitor urinary output to

determine body fluids gain or loss.

Urinary output should be at least

25mlhr or 600ml24h.

>Check clients weight to determine

fluid loss or gain. A loss of 2.2 to 2.5

lbs. Is equivalent to a fluid loss of 1liter.

>Administer slowly hearing loss

may occur if rapidly injected.


11/11

Pen G

THERAPEUTICCLASS

ACTION CONTRAINDICATION TOXIC EFFECT/SIDEEFFECT

NURSING MANAGEMENT

Rapid-

acting

antibiotic

Inhibits cell

wall synthesis

during

microorganism

multiplication.

Kills

susceptible

bacteria.

Contraindicated

in patient

hypersensitive

to drug or otherpenicillin.

Pain at injection

siteMonitor for penicilin

hypersensitivity, ototoxicity,

nephrotoxicity and

hepatotoxicity. It should betake wih meals.

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ncp with ds