Cues Nursing Scientific Planning Interventio Rationale Evaluation

Diagnos Explanation ns
is
S Risk for Without After 1 hour >Encourag >Protect the After 1 hour
O: infectio proper of proper e patient patient from of nursing
Presence of n wound care, nursing to opportunistic intervention
peritoneal opportunistic intervention maintain microorganis the patient
catheter under microorganis the patient strong ms. was able to
the umbilical ms from the will immune verbalize
cord(Ongoing environment verbalize system. understandi
Peritoneal may invade understandi >Emphasiz >Eliminates ng on how
Dialysis) the incision ng on how e the transient to minimize
-C IFC inserted site and to minimize importanc microorganis and prevent
patent and intact infection may and prevent e of proper ms. risk of
- occur. risk of hygiene having
having such as infection.
infection Hand
washing,
Wearing
gloves
when
cleaning
the site.

>Explain
the risk
factors and >Gives
possible information
effects of regarding the
having an complications
infected of infection
wound.

>Advise to
keep
dressing >Moisture
dry and serves as a
intact and medium for
use of microbial
Betadine growth.
or Plain
NSS.

>Advise to
increase
Vitamin C >Strengthens
intake immunity
against any
>Provide infection
health
teachings >Enables the
on proper client to
wound continue
 care practicing
proper
wound care.
>Change
dressing as
ordered by >Eliminates
the microorganis
physicaian m that are
enclosed with
the dressing.

Cues Nursing Scientific Planning Intervention Rationale Evaluation

Diagnosis Explanation
S: Madali Fatigue After 8 >Monitor the >The patient
akong related to hours of patients will need
mapagod decrease nursing nutritional adequate
Cardiac intervention intake for intake of
O: Output the patient adequate carbohydrate,
>weak and will be able energy vitamins, and
pale in to sources and minerals to
appearance demonstrate metabolic provide
>decreased energy requirement energy
performanc conservation s. sources.
e techniques
> to offset >Assist the >A plan that
fatigue. patient to balances
develop a periods of
schedule for activity with
daily activity periods of
and rest rest can help
the patient
complete
desired
activities
without
adding to
levels of
fatigue.

>Assist the >Conserves

client with energy,
ADL’s as permits
necessary; continuation
encourage of
independenc normal/requi
e without re activities
causing and provides
exhaustion. for patient’s
safety.

>Teach >These
strategies for strategies
energy decrease the
conservation amount of
(e.g. sitting energy used.
instead of
standing
during
showering
storing
items at
waist level).

>Minimize >Bright
environment lighting noise,
al stimuli, visitors,
especially frequent
during distractions,
planned and clutter in
times for rest the patient’s
and sleep. physical
environment
 can inhibit
relaxation,
interrupts
sleep/rest,
and
contributes to
fatigue.

>Help the >Promoting

parient relaxation
develop before sleep
habits to and providing
promote for several
effective hours of
rest/sleep uninterrupted
pattern. sleep can
contribute to
energy
restoration.

>Help the >Setting

patient set priorities is
priorities for one example
desired of energy
activities and conservation
role technique
responsibiliti that allows
es. the patient to
use available
to accomplish
important
activities.
Achieving
desired goals
can improve
patients
mood and
sense of
emotional
well being.

>Delegating
tasks and
>Encourage responsibilitie
the patient s to others
to identify can help the
tasks that patient
can be conserve
delegated to energy.
others
Cues Nursing Scientific Planning Intervention Rationale Evaluation
Diagnosis Explanation
S: Excess fluid When After 8 hours >monitor >excess fluid After 8
O: volume proteins are of Nursing vital signs increases hours of
>bi-pedal related to lost in the interventions every 4 the cardiac nursing
pitting retention of urine, the the patient hours. workload intervention
edema sodium and osmotic will edema Notify and blood the patient
noted on water as pressure of physician for pressure was able to
lower evidenced plasma falls significant
extremities( by bi-pedal responds changes
grade 2) pitting and fluid
>Crackles (grade shift into the >Monitor >Accurate
>CBC result 2)edema. interstitial intake and intake and
HCT:.210 spaces. The output output
HGB:69 body every 4 records help
> jugular responds to hours determine
vein the fluid fluid volume
distention shift by status
retaining
sodium and >to provide
water to >Weigh the a
maintain patient daily comparative
intravascular or on a baseline
volume, regular data
leading to n schedule as
excess indicated
volume. >to moisten
>Offer iced mucous
chips and membranes
frequent and help
mouth care relieve thirst
in relieving
thirst >To reduce
edema
>place 2
pillows on
below
extremities Furosemide
is a loop
>Administer diuretic
medication (water pill)
as that
prescribed: prevents
your body
Furosemide from
absorbing
too much
salt,
allowing the
salt to
instead be
passed in
your urine.

Furosemide
treats fluid
retention in
people with
congestive
heart
failure, liver
disease, or a
kidney
disorder
such as
nephrotic
syndrome.
This
medication
is also used
to treat high
blood
pressure.