Nursing Care Plan

ASSESSMENT Subjective: Kumikirot ang kamay ko. As verbalized by the patient Objectives: -(+) Facial grimace -Pain scale 6/10 -Elevated blood pressure 150/80mmHg -Increased in respiratory rate: 27 cpm. -Temperature is 39.0 C -Hand Tremor -Edema

DIAGNOSIS Acute Pain related to injuring agentsdistention of tissues by accumulation of fluid.

PLANNING Short term goal: - After 1 hour of nursing intervention the client will appear relax and able to sleep and participate in activities appropriately. Long Term Goal: -After days of hospitalization the Patient will manifest wellness. And continue the selfcare management.

INTERVENTION -Explained all the procedure to the client. -Monitored V/S of the Client including the Pain scale. -Used pain rating scale with 10 as the Highest. -Encouraged the Client to report feeling during and after nursing intervention -Assisted the client to position to where he was comfortable. -Encouraged the patient to have rest periods. -Informed the client for the Adverse effect and the indication of the drug given by the staff nurse.

RATIONALE -To enhance trust and decrease anxiety. -To obtained the baseline data for the Client. -To evaluate severity of pain sensation -To assess the effectiveness of the nursing interventions and obtain baseline for future comparison. -To provide comfort.

EVALUATION Short term Goal: Goal met, The patient was able to smile. To response and able to recite some instructions of the Nursing student.

-To prevent fatigue.

-To alleviate pain.

Nursing Care Plan ASSESSMENT Subjective cues: Bakit ang taas naman ng ng BP ko? As verbalized by the Patient. DIAGNOSIS Elevated blood pressure related to risk for prone behavior secondary to Lack of knowledge about the disease. PLANNING After 1 hour of nursing intervention, the client will verbalize understanding about the disease process and treatment. INTERVENTION
-Defined and state the limits of desired BP. Explained hypertension and its effect on the heart, blood vessels, kidney, and the brain. -Assisted the patient in identifying modifiable risk factors like diet high in sodium, saturated fats and cholesterol. -Reinforced importance of adhering to treatment regimen and keeping follow up appointments. -Suggested frequent position changes, leg exercises when lying down. -Helped patient identify sources of sodium intake. -Encouraged patient to decrease or eliminate caffeine like in tea, coffee, cola and chocolates. -Stress importance of accomplishing daily rest periods.

RATIONALE
-Provides basis for understanding elevations of BP, and clarifies misconceptions and also understanding that high BP can exist without symptoms or even when feeling well. -These risk factors have been shown to contribute to hypertension.

EVALUATION Goal met. After 1 and one half of nursing interventions the patient was able to enumerate some learnings about hypertension.

Objective cues: -BP taken 160/80mmHg compared to his previous BP 140/80mmHg -Pulse Rate of 67bpm -Respiratory rate of 27cpm -Requested for Information.

-Lack of cooperation is common reason of failure of antihypertensive therapy.

-Decreases peripheral venous pooling that maybe potentiated by vasodilators and prolonged sitting or standing. -2 years on moderate low salt diet may be sufficient to control mild hypertension. -Caffeine is a cardiac stimulant and may adversely affect cardiac function.

-Alternating rest and activity increases tolerance to activity progression.

Nursing Care Plan ASSESSMENT DIAGNOSIS PLANNING Short term goal: -After 2 hours of nursing intervention, the patient will manifest decrease in latest temperature. INTERVENTION -Assessed and monitored patients temperature and noted for presence of chills. -Applied tepid sponge bath every 15mins. RATIONALE -Temperature 38.9-41C may suggest acute infectious disease process. - It could help in reducing hyperthermia; avoid using alcohol and iced water which may even produce chills and increase clients temperature. - Providing health teachings to client could help client cope with disease condition and could help prevent further complications of hyperthermia. EVALUATION Goal met. The patient manifest lower of temperature after the drug is given.

Subjective cues: Nilalagnat nanaman ako. as verbalized by the patient.

Intermittent Fever related to direct effect of circulating endotoxins on hypothalamus resulting to an altered temperature regulation secondary to arthritis

Objective cues: -Shivering -Flushed skin, warm to touch -Restlessness V/S taken as follows: T- 39.0C P-67bpm R-27cpm BP-160/80mmHg

Long term goal: -After 3days of nursing intervention the patient will maintain the normal temperature and can do physical activities and of course disease free.

-Educate client of signs and symptoms of hyperthermia and help him identify factors related to occurrence of fever; discuss importance of increased fluid intake to avoid dehydration. - Encourage client to increase fluid intake.

- Water regulates body temperature.

-Paracetamol administered by the staff nurse.

- Paracetamol is commonly used for the relief of fever, headaches, and other minor aches and pains, and is a major ingredient in numerous cold and flu remedies.

Nursing Care Plan ASSESSMENT Subjective cues: Namamaga ang ang paa at kamay ko dahil sa naoverdose ako sa gamut. As verbalized by the patient. DIAGNOSIS Ineffective tissue perfusion: peripheral related to edema PLANNING Short term Goal: - After 1 day of nursing intervention the patient will identify changes in life style needed to increase tissue perfusion. Long term Goal: -After hospitalization, the patient will verbalized knowledge of treatment regimen, including appropriate ROM exercises and medications and their actions and possible side effects INTERVENTION -Elevated edematous legs as ordered RATIONALE -Elevations increases venous return and help decrease edema. -Skin pallor or mottling, cool or cold skin temperature or an absent pulse can signal arterial obstruction. This is an emergency that requires immediate intervention. -Thrombosis with clot formation is usually first detected as swelling of the involved leg and then as pain. -Ischemic feet are vulnerable to injury. EVALUATION -Goal met: the patient was able to identify changes in life style needed to increase tissue perfusion.

-Noted skin Color and feel the temperature of the skin.

Objective cues: -non pitting Edema on both hands and feet. - (+) facial grimace.

-Pain with 6/10.

-Observed for signs of deep vein thrombosis including pain, tenderness, swelling in the calf and thigh and redness. -Used protective padding. Foot cradles or alternating pressure mattress to reduce the risk of pressure injuries.

Nursing Care Plan ASSESSMENT Subjective cues: Ihi ako ng Ihi pero pakonti-konti lang ang iniinom kong tubig. As verbalized by the patient. Objective cues: -750cc urine output @ July 5, 2012(2:00pm6:00pm) -urine color is light yellow. DIAGNOSIS
Fluid volume deficit related to active fluid volume loss.

PLANNING
-after 4 hours of nursing intervention, the client will be able to maintain fluid volume at a functional level.

INTERVENTION
-Monitored and recorded vital signs including I and O

RATIONALE
-To provide baseline data for assessing and evaluating interventions -Predictors of fluid balance that should be in client usual range in a healthy state. -To detect early signs of dehydration.

EVALUATION Goal unmet And the IVF level at the end of my shift is from 360cc to240cc. Therefore the he consumed 120cc in 2:00pm-6:00pm. And he only drank 30ml oral fluid @ July 5, 2012 as of 2:00pm to 6:00pm.

-Noted physical signs of dehydration

-encourage fluid intake and monitored of daily fluid intake and output.

-Checked the color of the urine output.

-to provide baseline data for assessing the patient.

-IVF level received 360cc .9% Sodium Chloride x 12 @2:45pm