XIII. NURSING CARE PLAN CUES Subjective: Nahihirapan ako huminga, as verbalized by the client. NSG.

DIAGNOSIS Impaired gas exchange related to altered oxygen carrying capacity of blood as evidenced by increased respiratory rate. GOAL After 8 hours of nursing intervention, the client will demonstrate improved ventilation and absence of symptoms of respiratory distress NSG. INTERVENTION Independent: Elevate head of To maintain airway. bed/position client appropriately; provide airway adjuncts and suction, as indicated. Encourage Helps limit oxygen adequate rest and needs/consumption limit activities to . within client tolerance. Promote calm and restful environment. Provide psychological support, activelisten questions/concer ns. To reduce anxiety RATIONALE EVALUATION Goal met. After 8 hours of nursing intervention, the client was able to demonstrate absence of symptoms of respiratory distress

Objective: RR= 31 PR= 97 BP= 130/90 Nasal flaring (+) pallor in nail beds

Minimize blood loss from procedures (e.g. tests) Dependent: Administer medication as indicated (e.g. antibiotics) CUES Subjective: Nahihirapan ako huminga, as verbalized by the client. Objective: RR= 31 BP= 130/90 Nasal flaring (+) Hematuria (+) Edema Hg level= 11.1 gm/dl Capillary refill= 4 NSG. DIAGNOSIS Ineffective tissue perfusion related to decreased hemoglobin level concentration in blood as evidenced by increased respiratory rate and low hemoglobin level. GOAL After 8 hours of nursing intervention, the client will demonstrate increased perfusion as individually appropriate. NSG. INTERVENTION Independent:

To limit adverse effect of anemia

To treat underlying condition RATIONALE EVALUATION Goal partially met. After 8 hours of nursing intervention, the client was able to partially demonstrate increased perfusion.

Monitor vital signs To assess baseline data Check for calf tenderness Elevate HOB and maintain head in neutral position Encourage quiet, restful atmosphere Which may indicate thrombus formation To promote circulation To conserve energy/ lowers tissue oxygen demand

Caution client to avoid activities that increase cardiac workload Dependent: Administer medications with caution

To lower tissue oxygen demand

Drugs used to improve tissue perfusion also carry risk of adverse responses To decrease edema

Administer diuretics Collaborative: Assist with treatment of underlying condition (e.g. medication, fluid replacement)

To improve tissue perfusion

CUES

NSG. DIAGNOSIS

GOAL

NSG. INTERVENTION

RATIONALE

EVALUATION

Subjective: nakakatayo naman ako kunwari magbabanyo ganun pero dahan dahan lang kasi mabilis ako mapagod as verbalized by the client.

Activity Intolerance related to decreased hemoglobin as manifested by decreased hemoglobin

After 8 hrs. of nursing intervention the client will show increase sense of independence toward activities.

-Assess clients ability to stand and move about and degree of assistance necessary/ use of equipment. -increase exercise/activity level gradually. -provides positive atmosphere, while acknowledging difficulty of the situation for the client. -assist client with activities. -promote independence in self-care activities as tolerated. -encourage client to maintain

-to determine current status and needs associated with participation in needed/desired activities. -to conserve energy. -helps minimize frustration and rechannel energy.

Goal met.

Objective: -weak in appearance -decreased hemoglobin: -BP: from 130/90 mm Hg to 120/90 -HR: from 97 bpm to 84 bpm

-to protect client from injury. -to enhance clients ability to participate in activities. -to enhance sense of well-being.

positive attitude; suggest use of relaxation techniques. -Provide referral to other disciplines, such as exercise psychologist, psychological counseling/therap y, and physical therapist, as indicated. CUES Subjective: sabi nila naninilaw ako as verbalized by the client. Objective: -jaundice DIAGNOSIS Disturbed body image related to jaundice as manifested by negative feeling about oneself GOAL After 2 hrs. of nursing intervention the client will verbalize acceptance of self-situation. INTERVENTION -evaluate level of clients knowledge and anxiety related to situation, observe emotional changes. -listen to clients comments responses to the situation. -to develop individually appropriate therapeutic regimens.

RATIONALE

EVALUATION

-which may indicate Goal met. acceptance or nonacceptance of situation.

-different situations are upsetting to different people, depending on individual coping

skills and past experiences. -discuss concerns about fear of mutilation, prognosis, and rejection. -alert staff to monitor own facial expressions and other nonverbal behaviors. -involve patient in planning care and scheduling activities. -To address realities and provide emotional support. -because they need to convey acceptance and not revulsion when the clients appearance is affected. -enhance feeling of competency /selfworth, encourage independence and participation in therapy. -maintaining appearance enhances selfimage. RATIONALE EVALUATION

-assist with grooming needs as necessary. CUES DIAGNOSIS GOAL INTERVENTION

Subjective: Ano na bang nangyayarisa akin?, as verbalized by the client.

Deficient knowledge related to unfamiliarity with information resources as manifested by inappropriate behaviors

After 8 hours of nursing intervention, the client will verbalize understanding of condition/disease process and treatment

Determine clients ability/ readiness and barriers to learning Provide positive reinforcement Provide information relevant only to the situation Use short, simple sentences and concepts Provide active role for client in learning process

To assess clients emotional and mental capability To encourage continuation of effort To prevent overload To facilitate learning Promotes sense of control over situation and is means for determining that client is assimilating/ using new information To facilitate learning

Objective: -Confusion -Exaggerated behaviors

Goal met. After 8 hours of nursing intervention, the client was able to verbalize understanding of condition/disease process and treatment

Use gestures and facial expressions that help convey meaning and information