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XI.

NURSING MANAGEMENT

CONCEPT MAP Nsg. Dx: Imbalance nutrition: less than body


Nsg. Dx: requirement r/t inadequate food intake as evidenced
Decreased cardiac output r/t vascular Nsg. Dx: by lack of appetite.
resistance secondary to hyper ension Disturbed sleep pattern r/t fear of therapeutic Cues:
Cues: regimen [blood transfusion]
Lack of interest in foods; Weak and pale
increased BP, RR and decreased AR and PR. Cues:
Pale conjunctiva; Consumed ¼ of served meals
Treatment: Amplodipine 5mg, Losartan 50 mg Dark-big eyebags; Weak and pale; Drowsy;
Interventions: verbalized was not able to sleep the entire night Treatment: Heraclene 3 mg
Interventions:
- Have pt. lie down or in a comfortable position Interventions:
- Position the pt in a comfortable position.
-Monitored intake and output -Keep environment quiet for sleeping, eliminate
-Provide relaxing environment while eating.
-Have a patient use a commode or urinal. noise.
-Allow patient to choose foods she likes.
-Provided a restful environment by minimizing -Perform nursing procedures all at the same time if
controllable stressors and unnecessary possible before patient to go to sleep. -Provide companionship or assist the pt while eating
disturbances. to encourage nutritional intake
-Adjust lighting by providing curtains.

C/C: Difficulty of Breathing


Admitting Dx: Chronic Renal Failure 2o Hypertensive
Nephrosceloris
Nsg. Dx:
Nsg. Dx: Altered peripheral tissue perfusion Impaired urinary elimination r/t
r/t decrease circulating hemoglobin Nsg. Dx:
Cues:increased BP, RR and decreased AR urinary retention
Impaired gas exchange r/t ventilation- Cues:
and PR. HgB=46 perfusion imbalance.
Urine volume/fluid output= 100 cc within 8
Laboratories: Hematology Cues:increased BP, RR and decreased AR hours; + edema noted on both cheeks
Treatment: Blood transfusion and PR. HgB=46 Verbalized difficulty in voiding
Interventions: Treatment: Furosemide, 60 mg and
- Slow the pace of care. Allow the pt. extra time
Laboratories:Hematology Rowatinex 2 caps
to carry out activities. Interventions: Interventions:
-Provided peaceful environment - Position pt in Semi-fowler’s position Provide an environment that encourages
-Encouraged increased fluid intake toileting; and administer meds as ordered.
-Encouraged to eat serve meals
-Encouraged/Assisted the pt. to eat small meals
-Monitor post BT reactions.
frequently.
-Provided and encourage peaceful environment to
rest and sleep.