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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