Transcript
VII. NURSING MANAGEMENT A. IDEAL NURSING MANAGEMENT Nursing Care Plan Problem
Fluid Volume Excess related to decreased urine output
Ideal Nursing Intervention
Rationale
INDEPENDENT: 1. Be aware of risk factors - To assess causative or (e.g. cardiac failure, precipitating factor. cerebral lesions, renal or adrenal insufficiency, psychogenic polydipsia, decrease or loss of serum proteins) 2. Compare current weight - To evaluate degree of with admission and/or excess. previously stated weight. 3. Measure abdominal girth. - For changes may increasing fluid retention or edema. 4. Restrict sodium and fluid To intake as indicated. elimination fluid. DEPENDENT: 5. Administer medications (e.g. diuretics, cardiotonics, steroid replacement, plasma or albumin volume expanders)
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promote of excess
Promotes
in maintaining fluids in the body by excreting the fluid to decrease edema formation.
Problem
Imbalanced nutrition: less than body requirements related to anorexia
Ideal Nursing Intervention
Rationale
INDEPENDENT: 1. Assess weight, age, Provides body build, strength, comparative activity or rest level and so baseline. forth. 2. Note total daily intake.
- To reveal changes that should be made in patient’s dietary intake.
3. Restrict fat intake as - To correct control indicated underlying causative factors.
4. Assist regimen.
in
developing To establish a nutritional plan that meets individual needs.
DEPENDENT: 5. Administer - To meet metabolic pharmaceutical agents as needs of the body. prescribed e.g. Vitamin or minerals (iron) supplement.
Problem Activity intolerance related to fatigue or imbalance between oxygen supply and demand
Ideal Nursing Intervention
Rationale
INDEPENDENT:
1. Evaluate current - Provides comparative limitations or degree of baseline. deficit in light of usual status. 2. Adjust activities.
To overexertion.
prevent
3. Promote comfort - To enhance ability to measures and provide participate in activities. for relief of pain. 4. Encourage to perform - Helps to mobilize the exercises. body and increase peristalsis of the abdomen. DEPENDENT: 5. Administer stool - Facilitates defecation softeners as ordered by when constipated. the physician.
SOAPIE S O
“Ga lisod siya og ginhawa.” as verbalized by the significant others. ►22
cycles per minute ►Tachypnea ►Rapid and shallow breathing ►Nasal flaring ►O2
inhalation 10 liters per minute via nasal cannula
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Impaired gas exchange related to altered delivery of oxygen
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Long term: Within thirty minutes of nursing interventions, client will be able to demonstrate improved ventilation and adequate oxygenation of tissues by ABGs within patient’s normal limits and absence of symptoms of respiratory distress. Short term: At the end of five minutes client will be able to establish normal effective respiratory pattern. 1. Bedrest maintained. *Prevent over-exhaustion and reduces oxygen consumption and demand.
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2. Encouraged relaxation techniques and diversional activities. *Energy needs to facilitate resolution of infection. 3. Elevated head of bed proper positioning (semi-fowlers) done , deep breathing and effective coughing. *Promote maximal inspiration and expectoration to improve ventilation. 4. Encouraged verbalization of concerns and feelings. *Providing reassurance, enhancing sense of security.
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5. Administration of oxygen inhalation 10 liters per minute via nasal cannula. *Oxygen therapy maintains the oxygen demand and supply. At the end of 30 minutes of intervention, the patient was able to demonstrate improvement in oxygen and ventilation, absence of symptoms of respiratory distress and participated in actions to maximize oxygenation by bedrest, elevation of head of bed and oxygen inhalation administration.
SOAPIE S O A P
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“Nang hupong iyang ti-il.” as verbalized by the significant others. ►Bilateral
pitting edema noted ►Decrease sodium ►Poor skin turgor Impaired skin integrity related to edema Long Term: Within thirty minutes of nursing interventions, client will be able to maintain skin integrity, demonstrate behaviours or techniques to prevent skin breakdown Short Term: At the end of five minutes nursing interventions, client will be able to understand the importance of the interventions imparted. 1. Skin inspected on a daily basis. *To determine changes on the skin. 2. Massaged reddened areas. *Improves blood flow minimizing tissue hypoxia. 3. Frequently repositioned in bed. Assisted with active or passive range of motion. *Improves circulation or reduces time any one area is deprived of blood flow. 4. Skin care provided and minimized contact with moisture or secretion. *Excessive dryness or moisture damages skin and hastens breakdown.
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5. Administration of Furosemide 60mg IVTT as prescribed by the physician. *Diuretic promotes in maintaining fluids in the body by excreting the fluid to decrease edema formation. At the end of the nursing intervention, patient was able to maintain skin integrity. Demonstrated behaviors or techniques to prevent skin breakdown by massaging the area, repositioning and frequent skin care.
SOAPIE S
“Wala pa siya kalibang.” As verbalized by the significant others.
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►Decreased
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Altered bowel elimination related to decreased dietary intake
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Long Term: Within thirty minutes of nursing interventions, client will be able to establish or return pattern of bowel function, demonstrate changes in lifestyle as necessary. Short Term: At the end of five minutes nursing interventions, client will be able to verbalize understanding of the interventions imparted. 1. Encouraged to increase fluid intake of 2 500-3 000mL per day within cardiac tolerance. *Aid in stool consistency and maintain hydration status.
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bowel movement ►Decreased peristalsis of the abdomen ►Poor skin turgor
2. Advised to avoid foods that are gas forming. *Decrease gastric distress and abdominal distention. 3. Encouraged to eat food that are rich in fiber such as fruits and vegetables. *Food rich in fiber can help in preventing constipation. 4. Encouraged to perform exercises. *Helps to mobilize the body and increase peristalsis of the abdomen.
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5. Administer stool softeners as ordered by the physician. *Facilitate defecation when constipated. At the end of the nursing intervention, patient was able to report to a normal pattern of bowel function by drinking or increasing fluid intake, avoiding gas forming foods, eating foods rich in fibers, exercising regularly.
SOAPIE S O
“Hawoy iyang lawas.” As verbalized by the significant others. ►Fatigue ►Body
weakness ►Poor skin turgor A P
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Activity intolerance to fatigue or imbalance between oxygen supply and demand Long Term: Within thirty minutes of nursing interventions, client will be able to increase activity tolerance and absence of complication, demonstrate decrease in physiologic signs of intolerance. Short Term: At the end of five minutes nursing interventions, client will be able to verbalize understanding of the interventions imparted. 1. Promoted calm environment. *induces relaxation thus decreasing O2 consumption. 2. Advised to change position slowly and monitor abnormalities (dizziness). *Indicative of postural hypotension on cerebral hypoxia. 3. Instructed alternate rest periods with activity periods. *Maintain energy level and alternates additional strain on the cardiac and respiratory system. 4. Activity planned with the patient including activities that patient can do as much as possible. *Promote gradual return to normal activity level.
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5. Administration of oxygen inhalation 10 liters per minute via nasal cannula. *Oxygen therapy maintains the oxygen demand and supply. At the end of the nursing intervention, patient was able to increase activity intolerance and demonstrated a decreased in physiologic signs of intolerance by providing a calm environment, oxygen administration.
SOAPIE S
No Subjective Cue
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►Increase
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Risk for infection related to inadequate secondary defense and intubation Long Term: Within thirty minutes of nursing interventions, client will be able to prevent or reduce risk of infection and demonstrate techniques to promote safe environment Short Term: At the end of five minutes nursing interventions, client will be able to verbalize understanding of the interventions imparted. 1. Instructed to perform proper handwashing by all caregivers, maintaining sterile suction technique. *These factor may be the simplest but are the moist important keys to prevent of hospital acquired infection.
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WBC ►Immunocompromise ►Diabetes Mellitus
2. Advised to minimize visitors, avoid contact with persons with upper respiratory infection. *Individual is already compromised and is at increased risk for infection. 3. Instructed patient in proper secretion disposal. *Reduces transmission of fluid borne organisms. 4. Adequate hydration and nutrition maintained. *Helps improve general resistance to disease and reduce risk of infection from static secretions.
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5. Administer antimicrobials as indicated. *To kill microbes in the body and also it serve as prophylaxis. At the end of the nursing intervention, patient was able to prevent or reduce risk of infection and demonstrated techniques to promote safe environment by doing proper handwashing, avoiding contact, proper disposal of secretions, maintaining adequate by hydration and nutrition.
