NURSING CARE PLAN

NURSING DIAGNOSIS NO 1: Impaired gas exchange r/t altered oxygen supply.

Cues and Evidences

Outcome Criteria

Nursing Interventions

Rationale

Evaluation

Subjective:

At the end of the shift, pt. will be able to:

Independent: At the end of the shift, patient was able to:

Gihangak na pud ko as verbalized by the patient.

Elevate the HOB and position client properly.

a. Verbalize understandin g of causative factors and appropriate interventions.

To maintain airway

Encourage adequate rest and limit activities to within client tolerance. Instruct in the use of relaxation, stress-reduction techniques. Encourage to perform pursed lip breathing.

Helps limit oxygen needs or consumption

To promote optimal chest expansion and drainage of secretions To correct/ improve existing deficiencies

b. Participate in treatment regimen within level of ability.

Verbalized understanding of causative factors and appropriate interventions. Participated in treatment regimen within level of ability

Encourage frequent position changes and deep breathing or To promote chest expansion and drainage of coughing exercise.

secretions. Dependent:

Objective:

Provide supplemental oxygen To improve respiratory function

Restlessness Pale skin and appear shiny esp. at lower extremities and abdomen Nasal flaring RR- 43cpm

NURSING CARE PLAN NURSING DIAGNOSIS NO 2: EXCESS FLUID VOLUME RELATED TO DECREASED URINE OUTPUT,AND RETENTION OF SODUIM AND WATER

Cues and Evidences

Outcome Criteria

Nursing Interventions

Rationale

Evaluation

Subjective:

At the end of the shift, patient will be able to:

Independent:

At the end of the shift, patient was able to: a. To Obtain a baseline data and evaluating changes b. Fluid restriction will be determined on basis of weight, urine output, and response to therapy. c. Understanding promotes patient and family cooperation with fluid restriction d. To prevent increase of blood pressure a. Verbalized understanding of individuals dietary / fluid restriction. b. Experienced no signs of pulmonary edema. c. Blood pressure is decreased from 150/100 to 120/80

Nanghupong pa gyodtawunakongtiil as verbalize by the patient. Objective: -with bipedal pitting edema noted -oliguria as claimed by the patient

a.Monitor vital signs a. Verbalize understanding of individuals dietary/fluid restriction. b. Be free o sign of pulmonary edema. c. Blood pressure is decreased D. elevate head of the bed d. Excrete excess body fluid

B. encouraged to limit fluid intake.

C .explain to patient and family rationale for fluid restriction.

-dry, flaky skin -hypertension noted (bp, 150/100 mmhg)

d. Able to excrete excess body fluid

Dependent: To promote elimination of excess fluid

-Administer meds. (Diuretics)

NURSING CARE PLAN

NURSING DIAGNOSIS NO 3: ACTIVITY INTOLERANCE RELATED TO FATIGUE, ANEMIA RETENTION OF WASTE PRODUCTS

Cues and Evidences

Outcome Criteria

Nursing Interventions

Rationale

Evaluation

Subjective: Katulugonkomaskigbuntag pa gan, Kapoyan sad ko mag sigeoglihok as verbalized by the patient. Objective: -restlessnes -irritability -inability to concentrate

At the end of the shift, patient will be able to:

Independent: a. Encouraged alternating activity with rest b. Promote independence of self -care activities as tolerated c. . assess factors to activity intolerance a. promotes activity and exercise within limits and adequate rest b. to improve self esteem At the end of the shift, patient was able to:

a. Verbalized understanding of causative factors affecting sleep. b. Identify individually appropriate interventions to promote sleep. c. Participate in increasing level of activity and exercise d. Alternates rest

c. indicates factors contributing to severity of fatigue d. -these factors are known to disrupt sleep pattern.

a. Verbalized understanding of causative factors affecting sleep. b. Identified individually appropriate interventions to promote sleep.

-frequent yawning -weakness -pale

d. Encouraged to restrict self the use of caffeine and alcohol intake.

e. .Suggested abstaining from daytime naps.

e. because they impair ability to

and activity f. Recommended quite activities, such as reading/ listening to music in the evening.

sleep at night.

f.

to reduce stimulation so client can relax.

g. limit evening fluid intake.

g. to reduce need for nighttime elimination.