Post on 18-Feb-2017
Get Homework/Assignment Done Homeworkping.comHomework Help https://www.homeworkping.com/
Research Paper helphttps://www.homeworkping.com/
Online Tutoringhttps://www.homeworkping.com/
click here for freelancing tutoring sites
CUES
NURSING
DIAGNOSIS
SCIENTIFIC
EXPLANATION
OBJECTIVE
INTERVENTION
RATIONALE
EVALUATION
Subjective:Objective:>Patient is conscious and coherent>with ongoing IV of D5 0.3 NaCl 500cc X KVO>Vital signs: BP: 110/80 PR: 79 RR: 20 Temp: 37.2>patient is oliguric average of 10mL/hour>Hgb: 73Hct: 0.20(Normal Values: Hgb is 125-175g/L and Hct I 0.40-0.52 for male)>patient is restless
>Excess fluid volume related to inability of the kidney to excrete waste products
>Kidneys are responsible for the elimination of waste products in our body. If there is an alteration on the normal functioning of the kidney, there would be a problem in the excretion of waste products. Making the waste to stay in the circulation and excessive fluid may be the result because
>After four hours of nursing interventions; *there would be a stabilized fluid volume by increasing the urine output of the patient *the client verbalize an understanding of individual dietary/fluid restriction
>Establish rapport
>Monitor vital signs
>Monitor I and O
>Assess appetite and note for nausea or vomiting
>Restrict Na and fluid intake as indicated
>Administer medications such as
>to facilitate client and student nurse interaction
>to be able to monitor the changes in the condition of the client
>to monitor the normality of urine output
>to be able to know other reason which contributes to his
>After four hours, goal met as evidenced by: *an increase in urine output from 10mL to 30mL/hour *the client verbalized understanding of fluid restriction in his diet and began to implement it *patient is awake *patient always stay on bed
there are only intake but a limited amount of output because of the damaged of malfunctioning kidney.
diuretics as ordered
>Evaluate edematous extremities, change position frequently
>Discuss importance of fluid restriction and “hidden sources” of intake such as foods high in water content
>Identify “danger” signs requiring notification of healthcare provider.
condition
>to avoid further excess fluid accumulation
>to promote elimination of waste products
>to reduce tissue pressure and risk of skin breakdown
>for better understanding on why the client needs t restrict his fluid consumption
>to ensure timely evaluation
ASSESSMENT
NURSING DIAGNOSI
S
SCIENTIFIC EXPLANATIO
N
OBJECTIVE NURSING INTERVENTIO
N
RATIONALE EVALUATION
Subjective: Objective: >Patient is conscious and coherent>with ongoing IV of D5 0.3 NaCl 500cc X KVO>Vital signs:BP: 110/80PR: 79RR: 20Temp: 37.2
>Risks for infection related to environmental condition
>Risk for infection is the state in which an individual is at risks for being invaded by pathogenic organisms / microorganisms due to poor environmental sanitation to its surroundings
>After 5 hours of patient and student nurse interaction the patient will verbalize understanding and identify intervention to reduce risk for
>Establish rapport
>Encourage the pt. and the S.O to practice proper hand washing techniques
>Encourage the
> To gain the cooperation of the patient during the interaction
> To reduce or minimize the transfer of microorganisms
> To prevent
>Goal met because the patient as well as the SO practicing the interventions given
= poor sanitation
= unable to meet patients demands for personal care
= poor hygiene
= presence of insects in the surroundings
infection patient and the SO to practice environmental sanitation
>Encourage the patient to throw the garbage or trash properly
>Instruct the patient to eat foods rich in Vit. C like guava, oranges, calamansi etc…
>Encourage compliance to drug regimen
the spread of microorganisms in the surroundings
> To avoid insects and other microorganisms that carries viruses
> To increase body resistance
> For protection against infection