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Nursing Care Plan
Ineffective Tissue Perfusion related to decrease in hemoglobin count CUES NURSING SCIENTIFIC OBJECTIVE DIAGNOSIS EXPLANATION S=Ø Ineffective tissue perfusion O = the patient related to manifested: decrease in hemoglobin - Low hgb count (56) count (56) - Low hematocrit count ( .17) - Paleness - Pale Palpebral conjunctiva - Body weakness - Restlessn ess - Cold and clammy skin The patient may manifest - Bronchos pasm - Dysrhyth mias - Capillary Acute glomerulonephritis is an inflammation of the glomerular capillaries. Because of this inflammation the blood vessels, the kidney cannot adequately produce erythropoietin that leads to decrease in hgb and hct count, thus resulting to anemia. Because of this, the patient manifested pale palpebral conjunctiva and paleness. Then the oxygen being supplied in the body is not enough due to decrease production of RBC Short term: After 4 hrs of nursing interventions the patient will be able to verbalize understanding of condition and therapy regimen Long Term: After 5 days of nursing interventions the patient will be able to demonstrate increased perfusion as individually appropriate NURSING INTERVENTION - Establish rapport - Monitor record VS RATIONALE DESIRED OUTCOME Short term: The patient shall have verbalized understanding of condition and therapy regimen after 4 hours of nursing interventions
-To gain trust and cooperation and -To have baseline data a
-Assess pt. gen. -To have condition baseline data and note any abnormal Long Term: findings The patient shall have -Encourage -To conserve demonstrated quiet, restful energy/lower increased atmosphere tissue oxygen perfusion as demands individually appropriate after -Encourage early -To enhance 5 days of nursing ambulation once venous return interventions tolerated -Discourage -To improve and sitting/standing facilitates good for long periods, circulation wearing constrictive clothing, crossing legs
refill longer than 3 secs - Use of accessory muscle in breathing - Nasal flaring
by the kidney which are responsible for the oxygenation of tissues thus leading to ineffective tissue perfusion.
- Check for calf -May indicate tenderness thrombus formation - Elevate head -To increase of bed gravitational especially at blood flow night -Instruct to -To conserve avoid strenuous energy activity - Restrict sodium, fluid and fat intake as indicated - Instruct patient’s SO about food rich in iron -Regulate IVF As ordered -Promote adequate bed rest - Attend needs -Administer meds as ordered -To decrease excess fluid volume -To increase hgb count
-To maintain hydration -To promote wellness -To promote health -To promote recovery
Activity Intolerance related to muscle weakness ASSESSMENT NURSING DIAGNOSIS SCIENTIFIC EXPLANATION Activity intolerance is insufficient physiological or psychological energy to endure or complete required or desired daily activities. This is present for patient with AGN because patient with such condition can have decrease erythropoietin production since the glomerular tissues are inflammed. With this condition, the patient can have decrease level of hgb and hct. And since hgb is responsible for oxygenation of tissue, there will be decrease oxygen being delivered to the tissues of the body. As a compensatory OBJECTIVES INTERVENTION RATIONALE EXPECTED OUTCOME Short Term: The patient shall have verbalized understanding of the causative factors and necessary interventions after 4 hours of nursing interventions. Long Term: The patient shall have reported measurable increase in activity tolerance after 3 days of nursing interventions.
Activity Intolerance O = Patient related to manifested the muscle following: weakness aeb physical - body inactivity, Low hgb weakness - restless count (56) Low ness - physica hematocrit ( . l inactivity count 17) - Low hgb count Pale palpebral (56) conjunctiva - Low hematocrit paleness count ( . 17) - Pale palpebral conjunctiva - palenes s Patient may manifest the following: Dizzine
Short Term: After 4 hours of nursing interventions, the patient will be able to verbalize understanding of the causative factors and necessary interventions. Long Term: After 3 days of nursing interventions, the patient will be able to report measurable increase in activity tolerance.
- To obtain patient’s cooperation - To obtain baseline data -To identify contributing factors -To know the appropriate activity level - To prevent overexertion -To reduce fatigue
-Monitor and record VS -Note patient’s report of weakness, fatigue and pain -Identify activity needs or desired -Adjust activities -Plan care with rest periods between activities -Provide positive atmosphere, while acknowledging difficulty of the situation for the
- Helps to minimize frustration rechannel energy
ss - Vertigo - Confusi on - Altered mental status - Poor muscle tone
mechanism, the body will increase demand of oxygen by increasing the respiratory rate of the patient which results to fatigue. Because of this, there will be faster consumption of ATP leading to weaker contractions thus causing muscle weakness. And if the patient has muscle weakness, there will be activity intolerance.
client -Promote comfort - To enhance measures for ability to relief from pain participate in activities -Give patient information that provides evidence of daily progress -Assist patient to learn and demonstrate appropriate safety measures -Encourage client to maintain positive attitude - To sustain motivation
-To prevent injuries
- To enhance sense of wellbeing
Fatigue related to physiological factor:anemia ASSESSMENT S=Ø O = the patient manifested the following: - body weakness - restlessn ess - physical inactivity - Low hgb count (56) - Low hematocrit count ( .17) - Pale palpebral conjunctiva - paleness Patient may Manifest: - dizziness -confusion - poor muscle tone - vertigo NURSING DIAGNOSIS Fatigue r/t physiological factor:anem ia 2° to disease condition SCIENTIFIC EXPLANATION AGN is an inflammation of glomerular capillaries. Because of the inflammation, the function of the kidney for erythropoiesis is affected which results in decrease RBC production leading to anemia. The body now will have decrease hgb and hct level. And since hgb is responsible for oxygenation of tissue, there will be less oxygen supply to tissues of the body. The body then will compensate by increasing the respiratory rate OBJECTIVES Short Term: After 4 hours of nursing interventions, the patient will be able to identify basis of fatigue and individual areas of control Long Term: After 1 week of nursing interventions, the patient will be able to perform ADLs at level of ability. INTERVENTION Establish rapport Monitor and record VS Identify presence of physical and/or psychological disease states RATIONALE - To gain patient’s trust and cooperation - To obtain baseline data - To assess causative or contributing factor EXPECTED OUTCOME Short term: The patient shall have identified basis of fatigue and individual areas of control after 4 hours of nursing interventions. Long Term: The patient shall have performed ADLs at level of ability After 1 week of nursing interventions.
Determine ability - To assess degree of to participate in fatigue activities/level of mobility Note daily energy patterns Establish realistic goals with patient Plan care to allow individually adequate rest periods - Helpful in determining pattern or timing of activity - Enhances commitment to promoting optimal outcomes - To provide rest periods
-altered mental status
of the patient which may lead to fatigue.
Schedule activities for periods when patient has the most energy Provide environment conducive to relief of fatigue Assist with self care needs and ambulation as indicated Promote quiet and relaxing environment Encourage early ambulation once tolerated Avoid over stimulation/ under stimulation Discuss routines Instruct in stress
To maximize participation
- Temperature and level of humidity are known to affect exhaustion -To help patient to cope with fatigue
-To provide comfort
-To promote venous return and gradually increased patients ADL - Impaired concentration can limit ability to block competing stimuli - To promote sleep - To assist patient to
management skills of relaxation Instruct to avoid strenuous activity Instruct to eat nutritious foods and foods rich in iron Refer to physical or therapy as appropriate
cope with fatigue
-To conserve energy -to maintain weight and appropriate nutrition - To maintain strength and muscle tone and to enhance sense of well-being
Fluid volume excess r/t disruption of regulatory mechanism AEB by facial edema
ASSESSMENT S= Ø O= patient manifested: - facial edema c puffy eyelids - body malaise - cold and clammy skin - restle ssness - Low hgb count (56) - Low hematocr it count( . 17) - Album in: +1 The patient may manifest:
NURSING DIAGNOSIS Fluid volume excess r/t disruption of regulatory mechanism AEB by facial edema 2° disease condition
SCIENTIFIC EXPLANATION Acute glomerulonephritis is an inflammation of the glomeruli of the kidney. Children above 2y/o are at risk to have AGN caused mostly by an antrapment and collection of antigenantibody complexes in the glomerular capillary membrane. The inflammation causes damage to the kidney, thus altering the glomerular filtration rate that will eventually lead to excretion of albumin. With decreased albumin level will result to decrease colloidal oncotic pressure and will lead to shifting of fluid from intracellular to interstitial spaces causing the pt. to have edematous face, decrease hct, and hgb, and cold and clammy skin. because of this there is stasis of fluid,
OBJECTIVES Short term: After 4º of nursing interventions the pt will be able to verbalize understanding of individual fluid restrictions
INTERVENTION - Establish rapport - Monitor VS and note level of consciousness -Monitor I & O
RATIONALE - To gain the trust of the client - To have a baseline data and to reveal alteration - To reveal alteration in fluid status -To assess for the presence of confusion, personality changes and to check for cerebral edema _to promote wellness -To reduce/prev ent tissue pressure and risk of
EXPECTED OUTCOME Short term: The pt shall have verbalized understanding of individual fluid restrictions after 4 hours of nursing interventions
Long term: After 5 days of nursing interventions the pt. will be able to demonstrate reduction of the recurrence of fluid excess
-Evaluate pt. mental status
Long term: Pt. shall have demonstrated reduction of the recurrence of fluid excess after 5 days of nursing interventions
_Provide quite environment -Encourage frequent change in position
- Chang es in mental status - Gener alize edema - Dyspn ea - Chang es in respirator y pattern - Jugul ar vein distention
confirming the diagnosis of fluid volume.
nursing excess -Measure abdominal girth
skin breaksdown -To assess for increasing fluid and edema -To reduce further edema -To promote fluid excretion
- Restrict fluid/sodium intake as indicated -Administer diuretics as ordered
Self-care deficit related to weakness ASSESSMENT S= Ø NURSING DIAGNOSIS SCIENTIFIC EXPLANATION Because of impaired renal function, the kidneys can not produce erythropoietin, a substance necessary for hematopoiesis or RBC production. This event leads to anemia as evidenced by low level of hemoglobin which is primarily responsible for the transport of oxygen to the body. The patient is deprived of enough tissue oxygenation as hemoglobin drops to normal level. This may cause the patient to have pale palpebral conjunctiva and nail beds, tachycardia, dizziness, lethargy, drowsiness and muscular weakness. The patient’s energy reserve is depleted and experiences weakness. Because of such, the patient is not able to perform self-care OBJECTIVES SHORT TERM: After 3º of nursing intervention, the pt will be able to identify individual areas of weakness and needs for selfcare. INTERVENTION -Establish rapport -Determine current capabilities and barriers to participate in self-care RATIONALE -To gain trust of client EXPECTED OUTCOME
Self-care deficit related to O= weakness AEB The Patient unkempt hair manifested: untrimmed dirty toenails and -body fingernails weakness -pale palpebral conjunctiva -pale nailbeds -low hemoglobin count (56) -tachycardia -unkempt hair -untrimmed dirty toenails and fingernails - Low hgb count (56) - Low hematocri t count( . 17)
LONG TERM: After 2 days of nursing intervention, the pt will perform self-care activities within the level of own ability.
-Identify reasons difficulty self-care
-Determine hygiene needs and provide assistance as needed with
the SHORT TERM: the The pt shall have identified -Comprehensive individual functional areas of assessment weakness and included needs for independent self-care, performance of After 3º of basic ADL’s, nursing social intervention activities, sensory abilities and ability to LONG TERM: ambulate The pt shall have -Underlying performed cause affects self-care choice of activities intervention or within the strategies and level of own problem may ability, After be minimized 2 days of nursing -Meets the intervention needs while supporting patient participation
The patient may manifest: -dizziness -drowsiness -lethargy
activities like maintaining appearance at a satisfactory level as evidenced by unkempt hair and as well as poor personal hygiene as evidenced by untrimmed and dirty toenails and fingernails.
activities including care of hair, nails, skin and brushing of teeth -Prepares for -Determine increased individual independence strength and which enhance skills of patient self-esteem -Involve patient in formulation of plan of care at level of ability -Enhances sense of control and aids in cooperation and maintenance of independence -Enhances commitment to the plan and optimizes outcome
-Promote patient/SO participation in problem 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
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