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CUES

NURSIN
G
DIAGNO
SIS

SCIENTIFI
C
EXPLANAT
ION

OBJECTIV
E

INTERVENT
ION

RATIONAL
E

EVALUATI
ON

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: 73
Hct: 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

>After four
hours
of
nursing
interventio
ns;
*there
would be a
stabilized
fluid
volume by
increasing
the urine
output of
the patient
*the client
verbalize
an
understan
ding
of
individual
dietary/flu
id
restriction

>Establish
rapport

>Monitor
vital signs

>Monitor
and O

>to
facilitate
client and
student
nurse
interaction
>to be able
to monitor
the
changes in
the
I condition
of
the
client

>to
>Assess
monitor
appetite and the
note
for normality
nausea
or of
urine
vomiting
output
>to be able
>Restrict Na to
know
and
fluid other
intake
as reason
indicated
which

>After four
hours, goal
met
as
evidenced
by:
*an
increase in
urine
output
from 10mL
to
30mL/hou
r
*the client
verbalized
understan
ding
of
fluid
restriction
in his diet
and began
to
implement
it
*patient is
awake
*patient
always stay

fluid
may
be
the
result
because
there
are
only intake
but
a
limited
amount of
output
because of
the
damaged of
malfunction
ing kidney.

contribute on bed
s to his
condition

>Administer
medications
such
as
diuretics as >to
avoid
ordered
further
excess
fluid
>Evaluate
accumulati
edematous
on
extremities,
change
>to
position
promote
frequently
elimination
of
waste
>Discuss
products
importance
of
fluid >to reduce
restriction
tissue
and hidden pressure
sources of and risk of
intake such skin
as
foods breakdown
high
in
water
>for better
content
understan
ding
on
>Identify
why
the
danger
client

signs
requiring
notification
of healthcare
provider.

needs
t
restrict his
fluid
consumpti
on

>to ensure
timely
evaluation

ASSESSME
NT

NURSING
DIAGNOSI
S

Subjective:

>Risks

SCIENTIFIC
EXPLANATI
ON

for >Risk

OBJECTIV
E

for >After

NURSING
INTERVENTI
ON

5 >Establish

RATIONALE EVALUATIO
N

> To gain the >Goal

met

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
=
poor
sanitation
= unable
to
meet
patients
demands
for
personal
care
=
poor
hygiene
=
presence
of insects
in
the

infection
related
to
environmen
tal
condition

infection
is
the state in
which
an
individual
is
at risks for
being invaded
by pathogenic
organisms
/
microorganis
ms
due
to
poor
environmental
sanitation to
its
surroundings

hours
of
patient and
student
nurse
interaction
the patient
will verbalize
understandi
ng
and
identify
intervention
to
reduce
risk
for
infection

rapport

>Encourage the
pt. and the S.O
to
practice
proper
hand
washing
techniques
>Encourage the
patient and the
SO to practice
environmental
sanitation
>Encourage the
patient
to
throw
the
garbage
or
trash properly

cooperation
of the patient
during
the
interaction

because the
patient
as
well as the
SO
practicing
> To reduce the
or minimize interventions
the transfer given
of
microorganis
ms

> To prevent
the spread of
microorganis
ms in the
surroundings
> To avoid
insects
and
other
microorganis
ms
that
carries
viruses

>Instruct
the
patient to eat > To increase
foods rich in body

surroundi
ngs

Vit.
C like resistance
guava, oranges,
calamansi etc
>Encourage
compliance to
drug regimen
>
For
protection
against
infection