NURSING MANAGEMENT

a. Nursing Care Plan

Ineffective Tissue Perfusion related to decrease in hemoglobin count

CUES NURSING SCIENTIFIC OBJECTIVE NURSING RATIONALE DESIRED
DIAGNOSIS EXPLANATION INTERVENTION OUTCOME
S=Ø Ineffective Acute Short term: Short term:
tissue perfusion glomerulonephritis After 4 hrs of - Establish -To gain trust The patient shall
O = the patient related to is an inflammation nursing rapport and cooperation have verbalized
manifested: decrease in of the glomerular interventions the understanding of
hemoglobin capillaries. patient will be - Monitor and -To have a condition and
- Low hgb count (56) Because of this able to verbalize record VS baseline data therapy regimen
count (56) inflammation the understanding of after 4 hours of
- Low blood vessels, the condition and -Assess pt. gen. -To have nursing
hematocrit kidney cannot therapy regimen condition baseline data interventions
count ( .17) adequately and note any
- Paleness produce abnormal Long Term:
- Pale erythropoietin Long Term: findings The patient shall
Palpebral that leads to After 5 days of have
conjunctiva decrease in hgb nursing -Encourage -To conserve demonstrated
- Body and hct count, interventions the quiet, restful energy/lower increased
weakness thus resulting to patient will be atmosphere tissue oxygen perfusion as
- Restlessn anemia. Because able to demands individually
ess of this, the demonstrate appropriate after
- Cold and patient increased -Encourage early -To enhance 5 days of nursing
clammy skin manifested pale perfusion as ambulation once venous return interventions
palpebral individually tolerated
The patient may conjunctiva and appropriate
manifest paleness. Then -Discourage -To improve and
the oxygen being sitting/standing facilitates good
- Bronchos supplied in the for long periods, circulation
pasm body is not wearing
- Dysrhyth enough due to constrictive
mias decrease clothing,
- Capillary production of RBC crossing legs
refill longer by the kidney
than 3 secs which are - Check for calf -May indicate
- Use of responsible for tenderness thrombus
accessory the oxygenation of formation
muscle in tissues thus
breathing leading to - Elevate head -To increase
- Nasal ineffective tissue of bed gravitational
flaring perfusion. especially at blood flow
night

-Instruct to -To conserve

avoid strenuous energy
activity

- Restrict -To decrease

sodium, fluid excess fluid
and fat intake as volume
indicated

- Instruct -To increase hgb

patient’s SO count
about food rich
in iron

-Regulate IVF -To maintain

As ordered hydration

-Promote -To promote

adequate bed wellness
rest

- Attend needs -To promote

health

-Administer -To promote

meds as ordered recovery
Activity Intolerance related to muscle weakness

ASSESSMENT NURSING SCIENTIFIC OBJECTIVES INTERVENTION RATIONALE EXPECTED

DIAGNOSIS EXPLANATION OUTCOME

S=Ø Activity Activity Short Term: -Establish rapport - To obtain Short Term:
Intolerance intolerance is After 4 hours patient’s The patient shall
O = Patient related to insufficient of nursing cooperation have verbalized
manifested the muscle physiological or interventions, understanding of
following: weakness psychological energy the patient will -Monitor and - To obtain the causative
aeb physical to endure or be able to record VS baseline data factors and
- body inactivity, complete required or verbalize necessary
weakness Low hgb desired daily understanding -Note patient’s -To identify interventions after
- restless count (56) activities. This is of the report of contributing 4 hours of nursing
ness Low present for patient causative weakness, factors interventions.
- physica hematocrit with AGN because factors and fatigue and pain
l inactivity count ( . patient with such necessary Long Term:
- Low 17) condition can have interventions. -Identify activity -To know the The patient shall
hgb count Pale decrease needs or desired appropriate have reported
(56) palpebral erythropoietin Long Term: activity level measurable
- Low conjunctiva production since the After 3 days increase in activity
hematocrit paleness glomerular tissues of nursing -Adjust activities - To prevent tolerance after 3
count ( . are inflammed. With interventions, overexertion days of nursing
17) this condition, the the patient will interventions.
- Pale patient can have be able to -Plan care with -To reduce
palpebral decrease level of hgb report rest periods fatigue
conjunctiva and hct. And since measurable between
- palenes hgb is responsible for increase in activities
s oxygenation of activity
tissue, there will be tolerance. -Provide positive - Helps to
Patient may decrease oxygen atmosphere, minimize
manifest the being delivered to while frustration re-
following: the tissues of the acknowledging channel energy
body. As a difficulty of the
- Dizzine compensatory situation for the
ss mechanism, the body client
- Vertigo will increase demand
- Confusi of oxygen by -Promote comfort - To enhance
on increasing the measures for ability to
- Altered respiratory rate of relief from pain participate in
mental the patient which activities
status results to fatigue.
- Poor Because of this, -Give patient - To sustain
muscle there will be faster information that motivation
tone consumption of ATP provides
leading to weaker evidence of daily
contractions thus progress
causing muscle
weakness. And if the -Assist patient to -To prevent
patient has muscle learn and injuries
weakness, there will demonstrate
be activity appropriate
intolerance. safety measures

-Encourage client - To enhance

to maintain sense of well-
positive attitude being
Fatigue related to physiological factor:anemia

NURSING SCIENTIFIC EXPECTED

ASSESSMENT DIAGNOSIS EXPLANATION OBJECTIVES INTERVENTION RATIONALE OUTCOME

S=Ø Fatigue r/t AGN is an Short Term: Establish rapport - To gain patient’s Short term:
physiological inflammation of After 4 hours trust and cooperation The patient
O = the patient factor:anem glomerular of nursing shall have
manifested the ia 2° to capillaries. interventions, Monitor and - To obtain baseline identified basis
following: disease Because of the the patient will record VS data of fatigue and
condition inflammation, be able to individual
- body the function of identify basis of Identify presence - To assess causative areas of
weakness the kidney for fatigue and of physical or contributing factor control after 4
- restlessn erythropoiesis is individual areas and/or hours of
ess affected which of control psychological nursing
- physical results in disease states interventions.
inactivity decrease RBC Long Term:
- Low hgb production After 1 week Determine ability - To assess degree of Long Term:
count (56) leading to of nursing to participate in fatigue The patient
- Low anemia. The interventions, activities/level of shall have
hematocrit body now will the patient will mobility performed
count ( .17) have decrease be able to ADLs at level of
- Pale hgb and hct perform ADLs Note daily energy - Helpful in ability After 1
palpebral level. And since at level of patterns determining pattern or week of
conjunctiva hgb is responsible ability. timing of activity nursing
- paleness for oxygenation interventions.
of tissue, there Establish realistic - Enhances
Patient may will be less goals with commitment to
Manifest: oxygen supply to patient promoting optimal
tissues of the outcomes
- dizziness body. The body
-confusion then will Plan care to - To provide rest
- poor muscle compensate by allow individually periods
tone increasing the adequate rest
- vertigo respiratory rate periods
-altered mental of the patient
status which may lead
to fatigue. Schedule To maximize
activities for participation
periods when
patient has the
most energy

Provide - Temperature and

environment level of humidity are
conducive to known to affect
relief of fatigue exhaustion

Assist with self -To help patient to

care needs and cope with fatigue
ambulation as
indicated

Promote quiet -To provide comfort

and relaxing
environment

Encourage early -To promote venous

ambulation once return and gradually
tolerated increased patients ADL

Avoid over - Impaired

stimulation/ concentration can
under stimulation limit ability to block
competing stimuli

Discuss routines - To promote sleep

Instruct in stress - To assist patient to

 management cope with fatigue
skills of
relaxation

Instruct to avoid -To conserve energy

strenuous activity

Instruct to eat -to maintain weight

nutritious foods and appropriate
and foods rich in nutrition
iron

Refer to physical - To maintain strength

or therapy as and muscle tone and
appropriate to enhance sense of
well-being

Fluid volume excess r/t disruption of regulatory mechanism AEB by facial edema
ASSESSMENT NURSING DIAGNOSIS SCIENTIFIC OBJECTIVES INTERVENTION RATIONALE EXPECTED
EXPLANATION OUTCOME

S= Ø Fluid volume excess Acute Short term: - Establish - To gain Short term:
O= patient r/t disruption of glomerulonephritis is an After 4º of rapport the trust of The pt shall have
manifested: regulatory mechanism inflammation of the nursing the client verbalized
AEB by facial edema glomeruli of the kidney. interventions the understanding of
- facial 2° disease condition Children above 2y/o are pt will be able to - Monitor VS - To have a individual fluid
edema c at risk to have AGN verbalize and baseline restrictions after
puffy caused mostly by an understanding of note level of data and to 4 hours of
eyelids antrapment and individual fluid consciousness reveal nursing
- body collection of antigen- restrictions alteration interventions
malaise antibody complexes in
- cold the glomerular capillary -Monitor I & O - To reveal
and membrane. The alteration in
clammy inflammation causes fluid status
skin damage to the kidney, Long term:
- restle thus altering the Long term: -Evaluate pt. -To assess Pt. shall have
ssness glomerular filtration After 5 days of mental status for the demonstrated
- Low rate that will eventually nursing presence of reduction of the
hgb count lead to excretion of interventions the confusion, recurrence of
(56) albumin. With pt. will be able personality fluid excess after
- Low decreased albumin level to demonstrate changes and 5 days of nursing
hematocr will result to decrease reduction of the to check for interventions
it colloidal oncotic recurrence of cerebral
count( . pressure and will lead fluid excess edema
17) to shifting of fluid from
- Album intracellular to _Provide quite _to promote
in: +1 interstitial spaces environment wellness
causing the pt. to have
edematous face, -Encourage -To
The patient decrease hct, and hgb, frequent reduce/prev
may and cold and clammy change in ent tissue
manifest: skin. because of this position pressure
there is stasis of fluid, and risk of
- Chang confirming the nursing skin
es in diagnosis of excess breaksdown
mental fluid volume.
status -Measure -To assess
abdominal girth for
- Gener increasing
alize fluid and
edema edema
- Dyspn
ea - Restrict -To reduce
- Chang fluid/sodium further
es in intake as edema
respirator indicated
y pattern
- Jugul -Administer -To promote
ar vein diuretics as fluid
distention ordered excretion
Self-care deficit related to weakness

ASSESSMENT NURSING SCIENTIFIC OBJECTIVES INTERVENTION RATIONALE EXPECTED

DIAGNOSIS EXPLANATION OUTCOME

S= Ø Self-care deficit Because of impaired SHORT TERM: -Establish -To gain the SHORT TERM:
related to renal function, the After 3º of rapport trust of the The pt shall
O= weakness AEB kidneys can not produce nursing client have
The Patient unkempt hair erythropoietin, a intervention, the identified
manifested: untrimmed dirty substance necessary for pt will be able to -Determine -Comprehensive individual
toenails and hematopoiesis or RBC identify current functional areas of
-body fingernails production. This event individual areas capabilities and assessment weakness and
weakness leads to anemia as of weakness and barriers to included needs for
-pale evidenced by low level needs for self- participate in independent self-care,
palpebral of hemoglobin which is care. self-care performance of After 3º of
conjunctiva primarily responsible for basic ADL’s, nursing
-pale nailbeds the transport of oxygen social intervention
-low to the body. The activities,
hemoglobin patient is deprived of sensory abilities
count (56) enough tissue LONG TERM: and ability to LONG TERM:
-tachycardia oxygenation as After 2 days of ambulate The pt shall
-unkempt hair hemoglobin drops to nursing have
-untrimmed normal level. This may intervention, the -Underlying performed
dirty toenails cause the patient to pt will perform -Identify cause affects self-care
and have pale palpebral self-care reasons for choice of activities
fingernails conjunctiva and nail activities within difficulty in intervention or within the
beds, tachycardia, the level of own self-care strategies and level of own
- Low dizziness, lethargy, ability. problem may ability, After
hgb count drowsiness and be minimized 2 days of
(56) muscular weakness. The nursing
- Low patient’s energy reserve -Meets the intervention
hematocri is depleted and -Determine needs while
t count( . experiences weakness. hygiene needs supporting
17) Because of such, the and provide patient
patient is not able to assistance as participation
perform self-care needed with
The patient activities like activities
may maintaining appearance including care
manifest: at a satisfactory level as of hair, nails,
evidenced by unkempt skin and
-dizziness hair and as well as poor brushing of
-drowsiness personal hygiene as teeth
-lethargy evidenced by -Prepares for
untrimmed and dirty -Determine increased
toenails and fingernails. individual independence
strength and which enhance
skills of patient self-esteem

-Enhances
-Involve patient sense of control
in formulation and aids in
of plan of care cooperation
at level of and mainte-
ability nance of
independence

-Enhances
-Promote commitment to
patient/SO the plan and
participation in optimizes
problem outcome
identification
and decision
making
-Conserves
-Encourage energy, reduces
energy –saving fatigue and
techniques enhances pt’s
ability to
perform tasks

-Aids in
-Shampoo or maintaining
style hair as appearance
needed and
provide or
assist with
manicure
-Reduces risk of
-Encourage or gum disease/
assist in routine tooth loss and
mouth and enhances oral
teeth care daily health

-To meet
-Encourage nutritional
food and fluid demands
choices
reflecting
individual likes
especially those
rich in iron and
vitamin C