DATE

CUES

NEED

NURSING DIAGNOSIS Fluid volume deficit related to inadequate fluid intake

OBJECTIVES OF CARE After 2 days span of nursing care, my patient will be able to: a) Maintain fluid volume at a functional level as evidenced by individually adequate urinary output, stable vital signs, moist mucous membranes, and good skin turgor; b) Verbalize understanding of causative factors and purpose of individual therapeutic interventions and medications; and c) Demonstrate behaviors to

INTERVENTIONS

EVALUATION July 06, 2010

J U L Y 0 5 2 0 1 0

S: dli mn gud ko gnhan muinom pro kung mukaon ko, muinom ko pra diretso tulon pro dli pud kaau dghan

O: Decrease fluid intake 3:00 Acute weight PM loss Decrease skin turgor Weakness Dry mucous membrane Sunken eyes Thirst but refuses to drink Output greater than intake @

N U T R I T I O N A L M E T A B O L I C P A T T E R N

Rationale: Fluid volume disturbances results from loss of body fluids and occurs more rapidly when coupled with decrease fluid intake. Causes of FVD include abnormal fluid losses, decreased intake and third-space fluid shifts. The therapeutic goal is to treat the underlying disorder and return the extracellular fluid compartment to normal.

1. Establish rapport. To elicit patients trust and cooperation. 2. Determine effects of age. Very young and extremely elderly individuals are quickly affected by fluid volume deficit, and are least able to express need. For example, elderly people often have a decreased thirst reflex and/or may not be aware of water needs. 3. Monitor and document vital signs. Sinus tachycardia may occur with hypovolemia to maintain an effective cardiac output. Usually the pulse is weak and may be irregular if electrolyte imbalance also occurs. 4. Note change in usual mentation/behavior/fun ctional abilities. These signs indicate sufficient dehydration to cause poor cerebral

GOAL PARTIALLY MET After the 2 days span of nursing care, my patient was: a) Able to maintain fluid volume at a functional level as evidence by individual ly adequate urinary output (from 2020ml to 1020ml) but wasnt able to

Increase pulse rate and heart rate

monitor and correct deficit, as indicated, when condition is chronic.

perfusion and/or electrolyte imbalance. 5. Encourage the patient to drink prescribed fluid amounts: Place fluids at bedside within easy reach Provide fresh water and straw oral fluid replacement is indicated for mild fluid deficit and is a costeffective method for replacement treatment. Older patients have a decreased sense of thirst and may need ongoing reminders to drink. 6. Administer fluids and electrolytes, as indicated. Fluids used for replacement depend on 1.) the type of dehydration present (hypertonic/hypotonic), and 2.) the degree of deficit determined by age, weight, and type of condition causing the deficit. 7. Establish 24-hour

attain stable vital signs (RR22cpm), dry mucous membran e and poor skin turgor. b) Not able to verbalize understa nding causative factors and purpose of individual therapeut ic interventi ons and medicatio ns c) Able to demonstr ate behaviors

replacement needs and routes to be used (e.g., IV). Steady rehydration over time prevents peaks/valleys in fluid level. 8. Provide oral hygiene. Attention to mouth care promotes interest in drinking. 9. Limit intake of alcohol/caffeinated beverages. It tends to exert a diuretic effect. 10. Provide frequent oral and eye care. To prevent injury from dryness. 11. Discuss factors related to occurrence of deficit, as individually appropriate. Early identification of risk factors can decrease occurrence and severity of complications associated with hypovolemia.

to monitor and correct deficit, as indicated, when condition is chronic such as a slight increase in oral fluid intake and decrease in urine output.

DATE

CUES

NEED

NURSING DIAGNOSIS Activity Intolerance related to weakness secondary to exploratory laparotomy

OBJECTIVES OF CARE After 2 days span of nursing care, my patient will be able to: d) Demonstrat e a stable in physiologic al signs of intolerance as evidence by a stable vital signs; e) Use identified techniques to enhance desired activity; and f) Verbalizes and uses energy conservatio n

INTERVENTIONS

EVALUATION July 06, 2010 GOAL PARTIALLY MET After the 2 days span of nursing care, my patient was: d) Able to demonstr ate stable vitals signs: BP: 110/60 Temp: 37.3 RR: 20 PR: 89 CR:90 b.)not able to used identified techniques to enhanced desired activity; c.) not able to verbalize

J U L Y 0 5 2 0 1 0

Subjective: Maliponglipong man ko kung magbangon ko ug dli ko kadugay kung magbangon ko

@ 3:00 PM

Objective: Genera lized weakn ess; CBR without BRP; Side effects of medica tions

A C T I V I T Y E X E R C I S E P A T T E R N

Most activity intolerance is related to generalized weakness and debilitation secondary to acute or chronic illness and disease. This is especially apparent in older patients with a history of orthopedic, cardiopulmonary, diabetic, or pulmonary-related problems. The aging process itself causes reduction in muscle strength and functions, which can impair the ability to maintain activity. Activity intolerance

1. Establish guidelines and goals of activity with the patient and care giver Motivation is enhanced if the patient participates in goal setting. Depending on the etiological factors of the activity intolerance, some patients may be able to live independently and work outside the home. Other patients with chronic debilitating disease may remain homebound. 2. Refrain from performing procedures. Patients with limited activity tolerance need to prioritize tasks. 3. Progress activity

may also be related to factors such as obesity, malnourishment, anemia, side effects of medications (e.g., Beta-blockers), or emotional states such as depression or lack of confidence to exert oneself. Nursing goals are to reduce the effects of inactivity, promote optimal physical activity, and assist the patient maintain a satisfactory quality of life.

gradually, as with the following: a.) Dangling legs 10-15 minutes three times daily; b.) Deep breathing exercises three or more daily This prevents overexerting the heart and promotes attainment of short-range goals. 4. Promote emotional support while increasing activity. Promote a positive attitude regarding activities. patient may be fearful of overexertion and potential damage to the heart. Appropriate supervision during early efforts can enhance confidence. 5. Teach the patient

and uses energy conservatio n.

and caregiver to recognize signs of physical over activity. this promotes awareness of when to reduce activity. 6. Teach energy conservation techniques, such as the following: these reduce oxygen consumption, allowing more prolonged activity. a.) Sitting to do tasks standing requires more work. b.) Changing positions often. this distributes work to different muscle 7. Teach appropriate use of environmental aids (e.g., bed rails, elevating head of bed while patient

gets out the bed, chair in the bathroom). these conserve energy and prevent injury from fall.

DATE

CUES

NEED

NURSING DIAGNOSIS Acute pain related to tissue injury secondary to exploratory laparotomy Pain is an unpleasant and highly personal experience that may be imperceptible to others, while consuming all parts of the persons life. It is usually a response to actual tissue damage, so there may not be abnormal laboratory or radiographic reports despite real pain.

OBJECTIVES OF CARE At the end of my 8 hours span of care, my patient will be able to: a. report pain is controlled; b. follow prescribed pharmacolo gical regimen; and verbalize nonpharmacologic methods that provide relief.

INTERVENTIONS

EVALUATION

J U L Y 7, 2 0 1 0 @ 3PM

S >The patient verbalized, Agay!sakit. Sakit gihapon akong tinahian. >Ayaw lang hilabti sa akong tiyan banda kay sakit. O >vertical incision below the sternum bypassing the umbilicus up to 2 inches below the umbilicus >guarding of abdominal area >changes position slowly to avoid pain >irritable >changes in vital sign especially the cardiac rate

C O G N I T I V E P E R C E P T I O N P A T T E R N

1. Note location of surgical incision. this can influence the amount of postoperative pain experienced. 2. Note clients locus of control. individuals with external locus of control may take little or no responsibility for pain management. 3. Accept the clients description of pain. pain is a subjective experience and cannot be felt by others. 4. Observe non-verbal cues/pain behaviors. observation may/may not be congruent with verbal reports or may be only indicator present when client is unable to verbalize. 5. Monitor skin color/temperature and vital signs. these are usually

July 7, 2010 @ 11 pm GOAL PARTIALLY MET At the end of my 8 hours span of care, my patient was: a. unable to report control of pain; b. able to take all due oral medicatio ns for pain or analgesic s; and, able to verbalize, dapat mag deep breathing para dili mulala ang sakit sa akong samd.

and pulse rate >sighing >grimaced face >analgesic medications >Pain scale of 7 out of 10

altered in acute pain. 6. Determine clients acceptable level of pain/pain control levels. it varies with the individual and situation. 7. Note when pain occurs. to medicate prophylactically, as appropriate. 8. Provide comfort measures, and quiet environment. to promote nonpharmacological pain management. 9. Instruct in/encourage use of relaxation techniques such as focused deep breathing. to distract attention and reduce tension. 10. Administer analgesics as ordered. to maintain acceptable level of pain. Notify physician if regimen inadequate to meet pain control goal.

11. Encourage adequate rest periods. to prevent fatigue.

DATE

CUES

NEED

NURSING DIAGNOSIS

OBJECTIVES OF CARE

INTERVENTIONS

EVALUATION

J U L Y 5, 2 0 1 0 @ 3 pm

Subjective : Head eache Verbaliz ed: init man akung lawas

N U T R I T I O N A L

Temper ature of 38.4oC Skin is warm to touch

M E T A L

Hyperthermia related At the end of my to increase metabolic eight hour care, rate secondary to the patient will: hyperthyroidism Maintain core Rationale: temperature Patient with within hyperthyroidism normal frequently finds a range. normal room Be free of temperature too complicatio warm because of an n such as exaggerated irreversible metabolic rate and brain/ increased heat neurological production. damage Inentify underlying cause/ contributing factors and importance of treatment, as well as signs/ symptoms requiring further

Tepid sponge bath rendered independent nursing action should be done first to subside the fever of the patient before dependent nursing action. Re check the temperatute after 1530 min. R to determine if the procedure is effective in lowering the temperature Administer anti-pyretic drugs if intervention is ineffective per doctors order R to avoid condition from exacerbating Check patients chart R to note if there are other contributory factors of hyperthermia Monitor vital signs

07-05-10 11:00 PM

GOAL PARTIALLY MET

After my eight hour care the patient had maintain his temperature within normal range: 37.1oC

He demonstrated no signs of complications such as: irreversible brain damage Patient

M E T A B O L I C

evaluation or intervention. Demonstrat e behavior to monitor and promote normotherm ia. Be free from seizures activity.

to know if there are sudden changes in vital signs wich may indicate signs of infection Check hydration status of client R hyperthermia may precipitate dehydration Monitor/ record all source of fluid loss such as urine(

P A T T E R N

oligouria and/ or renal failure may occur due to hypotention, dehydration, shock, and tissue necrosis);vomiting and diarrhea; wounds/ fistulas; and insensible losses(R potential fluid and electrolyte losses ) Note presence/ absence of sweating as body attemps to increase heat loss by evaporation, conduction, and

a) b)

c)

was unable to increase OFI because of vomiting The client did not have seizures or signs that may lead to seizures Such as: Increase in BP Increase temperat ure Spasmic attract

VS: a) PR: 93bpm b) CR: 95bpm c) RR: 20cpm d) BP: 110/60

diffusion. R evaporation is decreased by environmental factors such as humidity and high ambient temperature, as well as body factors of high ambient temperature, as well as body factors producing loss of ability to sweat or sweat or sweat glands dysfunction Monitor intake and output R to replace loss fluid from diaphoresis.

e) Temp.: 37.1

DATE

CUES S: dili man gud ko ganahan muinom pero kung mukaon ko, muinom ko pra diretso tulon pero dli pud kaayu daghan as verbalized by patient

NEED

NURSING DIAGNOSIS Impaired Oral Mucous Membrane r/t Dehydration

J U L Y 0 5 2 0 1 0

@ 3:00 PM

O: Stomati tis on the right buccal mucosa White patches at both right and left buccal Dry mouth Cracke

N U T R I T I O N A L M E T A B O L I C P A T T E R N

Minor irritation of the mucous membrane occasionally occurs to any person. Dehydration can cause impaired oral mucous membrane because of the decrease moisture of the area. Since lubrication is not present, it can cause irritation.

OBJECTIVES OF CARE After 2 days span of nursing care, my patient will be able to: 1.) Have an intact oral mucosa as evidenced by: a. Clean oral cavity b. Free from lesions and stomatiti s 2.) Demonstrat e appropriate oral hygiene 3.) Verbalize relief from stomatitis

INTERVENTIONS

EVALUATION July 06, 2010 GOAL PARTIALLY MET After the 2 days span of nursing care, my patient was: 1. Oral cavity was clean but stomatitis and lesions are still present. 2. Able to do indipende nt appropria te oral hygiene 3. Stomatiti s was not relieved.

1. Assess status of oral mucosa; include tongue, lips, mucous membranes, gums, saliva, and teeth. These are frequent sites for infection and irritation. Patient or home caregivers also need to be informed of the importance of these assessments. 2. Determine nutrition/fluid intake and reported changes like avoiding eating and changes in taste. Indicates problems with oral mucosa 3. Assess medication use and possibility of side effects. Affects health or integrity of oral mucous membranes. 4. Evaluate clients ability to provide self-care

d lips Freque nt use of CB with water to be wiped in the patient s lips and tongue Small amount of fluid intake Acute weight loss Poor skin turgor Weakn ess Sunken eyes Thirst but refuses to drink Output greater

and availability of necessary equipment/assistance. clients current health affects ability to provide care. 5. Encourage to have adequate fluids. To prevent dry mouth and dehydration. 6. Encourage to have citrus foods and drinks, chewing gum, or hard candy. To stimulate saliva 7. Encourage gentle gum massage and tongue brushing with soft toothbrush or sponge/cotton tip applicators. limits mucosal/gum irritation. 8. Encourage to have saline rinse or diluted alcohol-free mouthwashes. To kill the bacteria present in the oral

than intake Increas e pulse rate and heart rate

mucosa. 9. Provide nutritional information. To correct deficiencies, reduce irritation/gum disease, prevent dental caries. 10.