ASSESMENT Subjective: “Okay na ako.” Objective: - received pt.

lying on bed ĉ ongoing IVF of PNSS 1L to run for 12˚ @ 850cc level, infusing well to left - conscious and coherent -ambulatory - ĉ non-productive cough - ĉ good skin turgor -ĉ good capillary refill - on soft diet - ĉ good appetite, consumed all food served - ĉ presence of active bowel sounds in the abdomen - voiding freely ĉ yellowish urine output - afebrile

DIAGNOSIS Readiness for Enhanced Therapeutic Regimen related to normal health status.

SCIENTIFIC EXPLANATION When the systems in the body respond well to medications and treatments it results to good health. Thus, our body is ready to regain its normal functioning.

PLANNING Within the 8˚ shift, the client will maintain normal health status and remain free from possible complications.

INTERVENTION Independent: - establish rapport

RATIONALE - to facilitate cooperation as well as to gain pt’s trust - to assure accuracy and completeness of knowledge based for future learning - it promotes sense of self-esteem and confidence to continue efforts - to maintain highlevel of well-being - to prevent possible complications - to broaden ideas that the pt may already have in order to reinforce positive behaviors - to note changes that can affect the pt’s condition - to promote optimum wellness

EVALUATION Goal met. Within the 8˚ shift, the client maintained normal health status and remained free from possible complications.

- assess the clients level of understanding of therapeutic regimen - accept client’s evaluation of own strengths or limitations while working together to improve abilities - help client’s needs, potential problems, and sources of stress - identify contributing factors that may need to be improve now or in the future - provide suggestions to the pt for sources of support that will help reinforce enhanced behaviors - take and record vital signs - provide health teachings such as: ☺ increase oral fluid intake ☺ instruct proper disposal of wastes ☺ emphasize the importance of proper hygiene ☺ review the manner of preparation

and storage of foods ☺ advise to avoid eating street foods Dependent: - to regulate IVF as ordered - to assure that the body receives accurate amount of fluids and electrolytes - to aid in the easy recovery - to serve as a guide in doing selfmedication that promotes independence

- to give due medications - instructed on home meds

ASSESMENT Subjective: “Okay na ako.” Objective: - received pt. lying on bed ĉ ongoing IVF of PNSS 1L to run for 12˚ @ 850cc level, infusing well to left - conscious and coherent -ambulatory - ĉ non-productive cough - ĉ good skin turgor -ĉ good capillary refill - on soft diet - ĉ good appetite, consumed all food served - ĉ presence of active bowel sounds in the abdomen - voiding freely ĉ yellowish urine output - afebrile

DIAGNOSIS Risk for fluid volume deficit related to excessive loss of fluids and electrolytes

SCIENTIFIC EXPLANATION When there is insufficient fluid intake, and excessive fluid loss from vomiting, and diarrhea it indicates imbalance in fluid volume in which the body can’t compensate by an adequate intake of water. Decreased volume in the intravascular compartment is called hypovolemia. Because water moves freely between the compartments, extracellular fluid deficit causes intracellular fluid deficit (cellular dehydration), which leaves the cells without adequate water to carry on normal function.

PLANNING Within the 8˚ shift, the client will not exhibit signs and symptoms of fluid volume deficit.

INTERVENTION Independent: - establish rapport - assess skin turgor and oral mucous membrane - monitor and record I & O balance being aware of insensible losses - weigh client and compare with recent weight history -monitor vital signs

RATIONALE - to facilitate cooperation as well as to gain pt’s trust - to note presence of dehydration -to ensure accurate fluid replacement therapy - to evaluate changes as related to fluid status - BP,RR, PR often increases when either fluid deficit or excess is present - to facilitate hydration - electrolyte imbalances may be present

EVALUATION Goal met. Within the 8˚, the client exhibited no signs and symptoms of fluid volume deficit AEB good skin turgor and moist oral mucous membranes.

- encourage increase oral fluid intake - note increase lethargy, hypotension, and muscle cramping Dependent: - regulate IVF as ordered

-administer diuretics and anti-emetics as prescribe

- to assure that the body receives accurate amount of fluids and electrolytes - to regain fluid volume balance

ASSESMENT Subjective: “Okay na ako.” Objective: - received pt. lying on bed ĉ ongoing IVF of PNSS 1L to run for 12˚ @ 850cc level, infusing well to left - conscious and coherent -ambulatory - ĉ non-productive cough - ĉ good skin turgor -ĉ good capillary refill - on soft diet - ĉ good appetite, consumed all food served - ĉ presence of active bowel sounds in the abdomen - voiding freely ĉ yellowish urine output - afebrile

DIAGNOSIS Risk for infection related to external factors

SCIENTIFIC EXPLANATION The immune system is the body's defense against bacteria, viruses and other foreign organisms or harmful chemicals. It is very complex and it has to work properly to protect us from the harmful bacteria and other organisms in the environment which may infect our body. If our immune system is compromised it can affect the normal production of white blood cells from the bone marrow. And if there is an increase in number of WBC it can therefore cause infection.

PLANNING Within the 8˚ shift, the client will remain free from the signs and symptoms of infection

INTERVENTION Independent: - establish rapport - note risk for occurrence of infection (e.g. compromised host) - instruct client/SO in techniques to prevent spread of infection - reinforce strict hand washing - encourage to maintain good health status by adequate hydration - provide regular perianal care - maintain sterile technique for invasive procedure Dependent: - emphasize necessity of taking antibiotics as directed - administer or monitor medication regimen and note client’s response

RATIONALE - to facilitate cooperation as well as to gain pt’s trust -to help in the immediate prevention - to educate them in the modes of transmission of the infection - serves a s a first line defense against infections - good health help in fighting infections - to reduce risk of ascending UTI - to prevent infection - premature discontinuation of treatment when client begins to feel well may result in return of infection - to determine effectiveness of therapy

EVALUATION Goal met. Within the 8˚, the client remained free from signs and symptoms of infection

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