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NCP

NCP

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Published by hsiria

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Published by: hsiria on Jun 03, 2009
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07/10/2013

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ASSESMENT DIAGNOSIS SCIENTIFICEXPLANATIONPLANNING INTERVENTION RATIONALE EVALUATIONSubjective:
“Okay na ako.”
Objective:
- received pt. lyingon bed ĉ ongoingIVF of PNSS 1L torun for 12˚ @ 850cclevel, infusing wellto left- conscious andcoherent-ambulatory- ĉ non-productivecough- ĉ good skin turgor-ĉ good capillaryrefill- on soft diet- ĉ good appetite,consumed all foodserved- ĉ presence of active bowel soundsin the abdomen- voiding freely ĉyellowish urineoutput- afebrileReadiness forEnhanced TherapeuticRegimen relatedto normal healthstatus.When the systemsin the bodyrespond well tomedications andtreatments itresults to goodhealth. Thus, ourbody is ready toregain its normalfunctioning.Within the 8˚shift, the clientwill maintainnormal healthstatus and remainfree from possiblecomplications.
Independent:
- establish rapport- assess the clientslevel of understandingof therapeutic regimen- accept client’sevaluation of ownstrengths orlimitations whileworking together toimprove abilities- help client’s needs,potential problems,and sources of stress- identify contributingfactors that may needto be improve now orin the future- provide suggestionsto the pt for sources of support that will helpreinforce enhancedbehaviors- take and record vitalsigns- provide healthteachings such as:☺ increase oralfluid intake☺ instruct properdisposal of wastes☺ emphasize theimportance of proper hygiene☺ review themanner of preparation- to facilitatecooperation as wellas to gain pt’s trust- to assure accuracyand completeness of knowledge based forfuture learning- it promotes senseof self-esteem andconfidence tocontinue efforts- to maintain high-level of well-being- to prevent possiblecomplications- to broaden ideasthat the pt mayalready have inorder to reinforcepositive behaviors- to note changesthat can affect thept’s condition- to promoteoptimum wellnessGoal met.Within the 8˚shift, the clientmaintainednormal healthstatus andremained freefrompossiblecomplications.
 
andstorage of foods☺ advise to avoideating street foods
Dependent:
- to regulate IVF asordered- to give duemedications- instructed on homemeds- to assure that thebody receivesaccurate amount of fluids andelectrolytes- to aid in the easyrecovery- to serve as a guidein doing self-medication thatpromotesindependence
 
ASSESMENT DIAGNOSIS SCIENTIFICEXPLANATIONPLANNING INTERVENTION RATIONALE EVALUATIONSubjective:
“Okay na ako.”
Objective:
- received pt. lyingon bed ĉ ongoingIVF of PNSS 1L torun for 12˚ @850cc level,infusing well to left- conscious andcoherent-ambulatory- ĉ non-productivecough- ĉ good skin turgor-ĉ good capillaryrefill- on soft diet- ĉ good appetite,consumed all foodserved- ĉ presence of active bowelsounds in theabdomen- voiding freely ĉyellowish urineoutput- afebrileRisk for fluidvolume deficitrelated toexcessive loss of fluids andelectrolytesWhen there isinsufficient fluidintake, andexcessive fluid lossfrom vomiting, anddiarrhea itindicatesimbalance in fluidvolume in whichthe body can’tcompensate by anadequate intake of water. Decreasedvolume in theintravascularcompartment iscalledhypovolemia.Because watermoves freelybetween thecompartments,extracellular fluiddeficit causesintracellular fluiddeficit (cellulardehydration),which leaves thecells withoutadequate water tocarry on normalfunction.Within the 8˚shift, the clientwill not exhibitsigns andsymptoms of fluidvolume deficit.
Independent:
- establish rapport- assess skin turgorand oral mucousmembrane- monitor and record I& O balance beingaware of insensiblelosses- weigh client andcompare with recentweight history-monitor vital signs- encourage increaseoral fluid intake- note increaselethargy,hypotension, andmuscle cramping
Dependent:
- regulate IVF asordered-administer diureticsand anti-emetics asprescribe- to facilitatecooperation as wellas to gain pt’s trust- to note presence of dehydration-to ensure accuratefluid replacementtherapy- to evaluatechanges as relatedto fluid status- BP,RR, PR oftenincreases wheneither fluid deficit orexcess is present- to facilitatehydration- electrolyteimbalances may bepresent- to assure that thebody receivesaccurate amount of fluids andelectrolytes- to regain fluidvolume balanceGoal met.Within the 8˚,the clientexhibited nosigns andsymptoms of fluid volumedeficit AEB goodskin turgor andmoist oralmucousmembranes.

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