VII. NURSING MANAGEMENT A.IDEAL NURSING MANAGEMENT Nursing Care Plan Problem Ideal Nursing Intervention Rationale Fluid Volume Excess related to decreased urine output INDEPENDENT: 1. Be aware of risk factors - To assess causative or (e.g. cardiac failure, precipitating factor. cerebral lesions, renal or adrenal insufficiency, psychogenic polydipsia, decrease or loss of serum proteins) 2. Compare current weight - To evaluate degree of with admission and/or excess. previously stated weight. 3. Measure abdominal girth. - For changes may increasing fluid retention or edema. 4. Restrict sodium and fluid To intake as indicated. elimination fluid. DEPENDENT: 5. Administer medications (e.g. diuretics, cardiotonics, steroid replacement, plasma or albumin volume expanders) of promote excess in maintaining fluids in the body by excreting the fluid to decrease edema formation. Promotes .To correct control indicated underlying causative factors. strength. 3. Provides body build. DEPENDENT: 5. 2.To reveal changes that should be made in patient’s dietary intake. Administer . . 4. prescribed e.g. Assist regimen. in developing To establish a nutritional plan that meets individual needs. Note total daily intake. Vitamin or minerals (iron) supplement. Assess weight. comparative activity or rest level and so baseline.To meet metabolic pharmaceutical agents as needs of the body.Problem Ideal Nursing Intervention Rationale Imbalanced nutrition: less than body requirements related to anorexia INDEPENDENT: 1. forth. Restrict fat intake as . age. deficit in light of usual status. the physician. . prevent 3.To enhance ability to measures and provide participate in activities. Promote comfort . 4. 2. body and increase peristalsis of the abdomen. Administer stool . Adjust activities. Encourage to perform . Evaluate current .Provides comparative limitations or degree of baseline.Problem Activity intolerance related to fatigue or imbalance between oxygen supply and demand Ideal Nursing Intervention INDEPENDENT: Rationale 1. for relief of pain. DEPENDENT: 5. To overexertion.Facilitates defecation softeners as ordered by when constipated.Helps to mobilize the exercises. enhancing sense of security. Short term: At the end of five minutes client will be able to establish normal effective respiratory pattern. absence of symptoms of respiratory distress and participated in actions to maximize oxygenation by bedrest. 3. Encouraged relaxation techniques and diversional activities.SOAPIE S O “Ga lisod siya og ginhawa. elevation of head of bed and oxygen inhalation administration. Bedrest maintained. At the end of 30 minutes of intervention. 2. Elevated head of bed proper positioning (semi-fowlers) done. deep breathing and effective coughing. *Energy needs to facilitate resolution of infection. ►22 cycles per minute ►Tachypnea ►Rapid and shallow breathing ►Nasal flaring ►O2 inhalation 10 liters per minute via nasal cannula Impaired gas exchange related to altered delivery of oxygen Long term: Within thirty minutes of nursing interventions. *Providing reassurance. the patient was able to demonstrate improvement in oxygen and ventilation. Administration of oxygen inhalation 10 liters per minute via nasal cannula. A P I E . 1. 5. *Prevent over-exhaustion and reduces oxygen consumption and demand. Encouraged verbalization of concerns and feelings. *Oxygen therapy maintains the oxygen demand and supply.” as verbalized by the significant others. *Promote maximal inspiration and expectoration to improve ventilation. client will be able to demonstrate improved ventilation and adequate oxygenation of tissues by ABGs within patient’s normal limits and absence of symptoms of respiratory distress. 4. Massaged reddened areas. 4. *Diuretic promotes in maintaining fluids in the body by excreting the fluid to decrease edema formation. repositioning and frequent skin care. ►Bilateral pitting edema noted ►Decrease sodium ►Poor skin turgor Impaired skin integrity related to edema Long Term: Within thirty minutes of nursing interventions. Skin inspected on a daily basis. *Improves circulation or reduces time any one area is deprived of blood flow. *To determine changes on the skin.” as verbalized by the significant others. client will be able to maintain skin integrity. client will be able to understand the importance of the interventions imparted. I E . 3. *Excessive dryness or moisture damages skin and hastens breakdown.SOAPIE S O A P “Nang hupong iyang ti-il. Demonstrated behaviors or techniques to prevent skin breakdown by massaging the area. Skin care provided and minimized contact with moisture or secretion. *Improves blood flow minimizing tissue hypoxia. 5. 2. Assisted with active or passive range of motion. 1. Administration of Furosemide 60mg IVTT as prescribed by the physician. At the end of the nursing intervention. patient was able to maintain skin integrity. Frequently repositioned in bed. demonstrate behaviours or techniques to prevent skin breakdown Short Term: At the end of five minutes nursing interventions. Encouraged to eat food that are rich in fiber such as fruits and vegetables. Short Term: At the end of five minutes nursing interventions. ►Decreased bowel movement ►Decreased peristalsis of the abdomen ►Poor skin turgor Altered bowel elimination related to decreased dietary intake Long Term: Within thirty minutes of nursing interventions. demonstrate changes in lifestyle as necessary. A P I E . *Facilitate defecation when constipated. Encouraged to increase fluid intake of 2 500-3 000mL per day within cardiac tolerance. 2. avoiding gas forming foods. Administer stool softeners as ordered by the physician. exercising regularly. patient was able to report to a normal pattern of bowel function by drinking or increasing fluid intake. *Food rich in fiber can help in preventing constipation. *Helps to mobilize the body and increase peristalsis of the abdomen. 5. client will be able to establish or return pattern of bowel function. client will be able to verbalize understanding of the interventions imparted. 1. At the end of the nursing intervention. *Decrease gastric distress and abdominal distention.” As verbalized by the significant others. eating foods rich in fibers. 3. *Aid in stool consistency and maintain hydration status.SOAPIE S O “Wala pa siya kalibang. 4. Advised to avoid foods that are gas forming. Encouraged to perform exercises. Activity planned with the patient including activities that patient can do as much as possible. *Maintain energy level and alternates additional strain on the cardiac and respiratory system. Instructed alternate rest periods with activity periods. *Promote gradual return to normal activity level. Administration of oxygen inhalation 10 liters per minute via nasal cannula. *Oxygen therapy maintains the oxygen demand and supply. ►Fatigue ►Body weakness ►Poor skin turgor Activity intolerance to fatigue or imbalance between oxygen supply and demand Long Term: Within thirty minutes of nursing interventions. A P I E . 1. Advised to change position slowly and monitor abnormalities (dizziness). *Indicative of postural hypotension on cerebral hypoxia. Promoted calm environment. client will be able to verbalize understanding of the interventions imparted.SOAPIE S O “Hawoy iyang lawas. 5. 2. 4. demonstrate decrease in physiologic signs of intolerance. Short Term: At the end of five minutes nursing interventions.” As verbalized by the significant others. *induces relaxation thus decreasing O2 consumption. oxygen administration. At the end of the nursing intervention. client will be able to increase activity tolerance and absence of complication. patient was able to increase activity intolerance and demonstrated a decreased in physiologic signs of intolerance by providing a calm environment. 3. Advised to minimize visitors. 4. 3. avoiding contact. Instructed to perform proper handwashing by all caregivers. *To kill microbes in the body and also it serve as prophylaxis. *These factor may be the simplest but are the moist important keys to prevent of hospital acquired infection. avoid contact with persons with upper respiratory infection.SOAPIE S O No Subjective Cue ►Increase WBC ►Immunocompromise ►Diabetes Mellitus Risk for infection related to inadequate secondary defense and intubation Long Term: Within thirty minutes of nursing interventions. proper disposal of secretions. Administer antimicrobials as indicated. 1. *Helps improve general resistance to disease and reduce risk of infection from static secretions. *Reduces transmission of fluid borne organisms. Adequate hydration and nutrition maintained. *Individual is already compromised and is at increased risk for infection. client will be able to prevent or reduce risk of infection and demonstrate techniques to promote safe environment Short Term: At the end of five minutes nursing interventions. patient was able to prevent or reduce risk of infection and demonstrated techniques to promote safe environment by doing proper handwashing. maintaining adequate by hydration and nutrition. A P I E . At the end of the nursing intervention. 5. 2. Instructed patient in proper secretion disposal. client will be able to verbalize understanding of the interventions imparted. maintaining sterile suction technique.