VI. NURSING CARE PLAN

ASSESSMENT DATA

(Subjective & Objective Cues)

NURSING DIAGNOSIS(Problem and Etiology)

GOALS AND OBJECTIVES

NURSING INTERVENTIONS AND RATIONALE

EVALUATION

Subjective:

“ …. Gamay ra akong ma-ihi…” as verbalized by the patient.

Objective:

Edema

Decreased Hb (8.4) /Hct (26.2)

Change in mental status: restless

Abnormal increase of abdominal girth (77cm)

Excess fluid volume related to accumulation of fluids in the body secondary to acute glomerulonephritis

Short-term Goals:

After 3 hours of thorough nursing intervention, the patient will be able to:

a. Gradually excrete excessive fluid through urination.

b. Demonstrate behaviors that would help in excreting excessive fluids in the body.

Long- term Goals:

After 2 days of thorough nursing intervention, the client will be able to:

a. Excrete

Independent:

1. Elevate edematous extremities, change position frequently.R: To reduce tissue pressure and risk of skin breakdown.

2. Assist and/or encourage client to turn to sides every 2 hours.R: it aids in the mobilization of fluids to easily excrete through urination.

3. Allow client to hear running water.

R: to promote diuresis

4. Apply hot and cold compress on the client’s bladder (just above symphisis pubis).

R: to stimulate urination.

5. Encourage bed rest if ascites is present.

R: May promote recumbency-induced diuresis

Short-term Goals:

Goals met. After 3 hours of thorough nursing intervention, the patient was be able to gradually excrete excessive fluid through urination and demonstrated behaviors that would help in excreting excessive fluids in the body.

Long- term Goals:

Goals met. After 2 days of thorough

VI. NURSING CARE PLAN

completely excessive fluids as manifested by the absence of edema.

b. Improve the distended abdominal girth from 77cm to 67cms.

Dependent :

1. Administer diuretic (furosemide 20 mg IVTT every 8 hours; spironolactone 25 mg 1 tab BID), as ordered

R: To increase water excretion.

2. Administer albumin 20% IVTT for 30 minutes every 12hours

R: because it helps in the shifting of fluids from ISC to IVC.

nursing intervention, the client was be able to excrete completely excessive fluids as manifested by the absence of edema and improved the distended abdominal girth from 77cm to 67cms.

VI. NURSING CARE PLAN

ASSESSMENT DATA

(Subjective & Objective Cues)

NURSING DIAGNOSIS(Problem and Etiology)

GOALS AND OBJECTIVES

NURSING INTERVENTIONS AND RATIONALE

EVALUATION

Subjective “ gahangakon ko ug galisod ko ug ginhawa usahay, “ as verbalized by the patient.

Objective

- Increase respiratory rate of 32 cpm (tachypneic)

- Abnormal increase of abdominal girth of 77cms

- Restless

Ineffective Breathing Pattern related to accumulation of fluid in the peritoneal cavity secondary to Ascites

Short Term Goals:

After 15 min. of nursing interventions, the patient will be able to:

a. Improve respiratory rate from 32cpm to 30 cpm.

b. Demonstrate and participate on the treatment given to relieve the condition.

c. Improve the client’s behavior from restless to responsive by answering questions that are being asked.

Long-Term Goals:After 1 day of thorough nursing intervention, the client will be able to:

a. achieve and maintain normal

Independent:

1. Assist client in proper deep breathing exercises.R: To promote good lung expansion.

2. Position client in Semi-fowler’s position. Elevating the head of bed.R: To prevent compression of the diaphragm by allowing the organs in the peritoneal cavity to lower down.

3. Encourage adequate rest periods between activities.R: To avoid overexertion.

4. Instruct client and/or significant others not to allow client wear tight dresses.

R: to promote proper lung expansion thus, proper breathing.

Dependent:

3. Administer diuretic (furosemide 20 mg IVTT every 8 hours; spironolactone 25 mg 1 tab BID), as ordered

Short-term Goals:

Goals met.After 15 min. of nursing interventions, the patient was able to Improve respiratory rate from 32cpm to 30 cpm, demonstrated and participated on the treatment given to relieve the condition and improved the client’s behavior from restless to responsive by answering questions that are being asked.

Long-Term Goals:

VI. NURSING CARE PLAN

range of respiration (15 – 22cpm)

b. Improve the distended abdominal girth from 77cm to 67cms.

R: To increase water excretion.

1. Administer albumin 20% IVTT for 30 minutes every 12hours

R: because it helps in the shifting of fluids from ISC to IVC.

Goals partially met. After 1 day of thorough nursing intervention, the client was able to improve the distended abdominal girth from 77cm to 67cms but fails to achieve and maintain normal range of respiration (15 – 22cpm).

ASSESSMENT DATA NURSING DIAGNOSIS GOALS AND NURSING INTERVENTIONS AND EVALUATION

VI. NURSING CARE PLAN

(Subjective & Objective Cues) (Problem and Etiology) OBJECTIVES RATIONALE

Subjective “ Luya man ko ug dali ra ko kapuyon, “ as verbalized by the patient.

Objective:

- Abnormal decrease of RBC 2.96

- Abnormal decrease of hemoglobin 7.6

- Abnormal decrease of hematocrit 23.4

- Pale conjunctivae- Pallor skin- Restless - Weak peripheral pulses

Ineffective Tissue perfusion(peripheral) related to decreased hemoglobin concentration secondary to anemia

Short –Term Goals:

After 2hrs. of nursing interventions, the patient will be able to:

a. Participate and demonstrate various ways to achieve effective tissue perfusion.

b. Improve the client’s behavior from restless to responsive by answering questions that are being asked.

Independent:

1. Assist patient in ambulation.R: To promote venous return.

2. Inform the patient not to stand/sit for long periods. R: Prevent venous stasis.

3. Assist patient in passive or active range-of-motion.R: To allow circulation.

4. Turn to side every 2 hrs.R: to allow proper blood circulation

Dependent:

1. Administer Packed RBC 450ml for 4 – 6 hours, as ordered.

R: To enhance oxygen carrying capacity of the body.

Short-Term Goals.

Goals met After 2hrs. of nursing interventions, the patient was be able to participate and demonstrate various ways to achieve effective tissue perfusion and improved the client’s behavior from restless to responsive by answering questions that are being asked.

VI. NURSING CARE PLAN

ASSESSMENT DATA

(Subjective & Objective Cues)

NURSING DIAGNOSIS(Problem and Etiology)

GOALS AND OBJECTIVES

NURSING INTERVENTIONS AND RATIONALE

EVALUATION

Subjective:

“Laay kaayo magpuyo diri sa hospital ma’am, gusto na bia gusto na ko makigdula sa ako mga amigo,” as verbalized by the patient.

Objective:

> restless> bored > Over eating

Deficient Diversional Activity related to fatigue and malaise.

After 35 minutes of nursing interventions, the patient will be able to:

> validate reality of environmental deprivation.

> note impact of illness on lifestyle.

Independent:

> Acknowledge reality of situation and feelings of the client *To establish therapeutic relationship

> Review history of activity/hobby preferences and possible modifications.

> Provide for physical as well as diversional activities.

> Encourage mix of desired activities/stimuli (music, story books). *Activities need to be personally meaningful for patient to derive the most enjoyment.

Collaborative:

Involve occupational therapist as appropriate.

*To help identify specific activities to individual situation.

Goals were met.

After 35 minutes of nursing interventions, the patient was able to:

> validate reality of environmental deprivation.

> note impact of illness on lifestyle.

VI. NURSING CARE PLAN

ASSESSMENT DATA

(Subjective & Objective Cues)

NURSING DIAGNOSIS(Problem and Etiology)

GOALS AND OBJECTIVES

NURSING INTERVENTIONS AND RATIONALE

EVALUATION

Subjectve:

“gahangakon ko basta grabeh ang dula” as verbalized by the patient

Objective:

- Abnormal decrease of RBC 2.96

- Abnormal decrease of hemoglobin 7.6

- Abnormal decrease of hematocrit 23.4

- pale skin- restlessness- increase respiration rate

of 32cpm (tachypneic)

Activity Intolerance (Level 1) related to imbalance between oxygen supply and demand secondary to anemia

Short-term Goals:After 15minutes of thorough nursing intervention, the client will be able to:a Improve his respiration from 32 cpm to 30 cpm.b. Demonstrate responsiveness by answering questions.c. verbalize the activity intoleranceLong-Term Goals:After 8 hours of thorough nursing intervention, the client will be able to:

a. achieve and maintain normal range of respiration (15 – 22cpm)

b. Ambulate independently without problems in

Independent:

1. Position client in Semi-fowler’s position. R: to promote proper lung expansion.

2. Assist client during ambulation.R: to promote circulation

3. Encourage rest periods fro client and avoid exertion on unnecessary activities.

R: to conserve energy consumption.

4. Listen to the client’s verbalization about the problem

R: it will encourage verbalization of feelings.

Dependent:

1. Administer Packed RBC 450ml for 4 – 6 hours, as ordered.

R: To enhance oxygen carrying capacity of the body.

Short-Term Goals.

Goals met. After 15minutes of thorough nursing intervention, the client was able to improve his respiration from 32 cpm to 30 cpm and demonstrated responsiveness by answering questions and verbalized the activity intolerance.Long-Term Goals:

Goals partially met. After 8 hours of thorough nursing intervention, the client was able to ambulate independently

VI. NURSING CARE PLAN

respiration. without problems in respiration.But failed to achieve and maintain normal range of respiration (15 – 22cpm).

ASSESSMENT DATA

(Subjective & Objective Cues)

NURSING DIAGNOSIS(Problem and Etiology)

GOALS AND OBJECTIVES

NURSING INTERVENTIONS AND RATIONALE

EVALUATION

VI. NURSING CARE PLAN

Risk Factors:

- Two days without defecation

- Restless- Decrease bowel sounds

(3 counts)

Risk for Constipation related to irregular defecation habits

Short-Term Goals:After 45 minutes of thorough nursing intervention, the client will be able to:

a. Gradually defecate feces within the body.

b. Improve client’s status from restless to responsive.

c. Improve bowel sounds from 3 counts to 5 counts.

Long-Term Goals:After 1 day of thorough nursing intervention, the client will be able to;

a. Maintain bowel habit in accordance to his time preference.

b. Maintain bowel sounds within the normal range.

Independent: 1. Encourage client to increase fiber intake in his diet.R: to improve consistency of stool and facilitate passage through colon.

2. Promote adequate fluid intake.R: to promote soft stool and stimulate bowel activity.

4. Assist client in doing Range of Motion.

R: to stimulate contraction of the intestines.

5. Encourage client on frequent ambulation;

R: this will promote peristaltic movement.

Dependent:

1. Administer laxative (senna concentrates, PRN), as ordered.R: to soften the stool thus, promote defecation.

Short-Term Goals:Goals met. After 45 minutes of thorough nursing intervention, the client was be able to gradually defecate feces within the body, improved client’s status from restless to responsive and improved bowel sounds from 3 counts to 5 counts.Long-term Goals:Goals partially met. After 1 day of thorough nursing intervention, the client was able to Maintain bowel sounds within the normal range but failed to maintain bowel

VI. NURSING CARE PLAN

habit in accordance to his time preference.

ASSESSMENT DATA

(Subjective & Objective Cues)

NURSING DIAGNOSIS(Problem and Etiology)

GOALS AND OBJECTIVES

NURSING INTERVENTIONS AND RATIONALE

EVALUATION

Subjective:

“sakit diri dapit sa hawak…” as verbalized by the patient.

- Pain scale of 6/10

Objective:

> restless> muscle guarding> facial grimace whenever the location of pain is touched.

Acute pain related to inflammation of the renal cortex secondary to acute glomerulonephrtis.

After 1 hour of nursing interventions, the patient will be able to:

> demonstrate nonpharmalogical methods that provide relief

> improve restlessness >verbalize the decrease of pain from 6 to 3 scale

Independent:

> observe nonverbal pain behaviorR: observation may not be congruent with verbal reports

>provide comfort measures, quiet environment and calm activitiesR: to promote nonpharmacological pain management> encourage use of relaxation techniques such as focus ed breathing and imagingR: to distract attention and reduce tension

> .review procedures and tell patent when

Goals were met.

After 1 hour of nursing interventions, the patient was able to:

>demonstrate nonpharmalogical methods that provide relief

> improve restlessness

VI. NURSING CARE PLAN

treatment may cause pain.R: to reduce concern of the unknown and associated muscle tension.

Collaborative:

Involve occupational therapist as appropriate.

*To help identify specific activities to individual situation.

>verbalize the decrease of pain from 6 to 3 scale