ncp with ds
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Transcript of ncp with ds
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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.
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8/8/2019 ncp with ds
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.
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8/8/2019 ncp with ds
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
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8/8/2019 ncp with ds
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
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8/8/2019 ncp with ds
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
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8/8/2019 ncp with ds
6/11
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8/8/2019 ncp with ds
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.
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8/8/2019 ncp with ds
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).
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8/8/2019 ncp with ds
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.
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8/8/2019 ncp with ds
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.
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8/8/2019 ncp with ds
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.