XI.

LIST OF IDENTIFIED PROBLEMS (LIST OF PRIORITY)

Assessment Nursing Analysis Planning Intervention Rationale Evaluation

Diagnosis
Subjective: INEFFECTIVE Acute Short term: -Establish rapport - to asses precipitating and Short term:
“lagi akong TISSUE glumerulonephritis Within 7-8hrs of causative factors After 8hrs of
nahihilo” as PERFUSION nursing intervention -assessed and monitored vital -general indicators of nursing
verbalized by the RELATED TO the client will able signs, skin color, sensation, circulatory status and intervention goal
Inflammation of to: movement, and capillary adequancy of perfusion
patient ANEMIA was partially met,
refill on extremities
glomerular as evidenced by:
-demonstrate -assess presence, location -useful in identifying or
Objective: capillaries increase perfusion and degree of swelling or quantifying edema in -partially
 pale palpebral as individually edema formation involved extremity demonstrate
conjunctiva appropriate -inspect lower extremities for -that often accompany increased in
 pale lips Kidney cannot skin texture and skin breaks diminished peripheral perfusion as
 present of produce Long term: or ulcerations circulation individually
edema on both erythropoietin Within 1-2weeks of -palpate arterial pulses -to determine level of appropriate
lower nursing intervention circulatory blockage
extremities the patient will: -check for calf tenderness or -indicators of deep vein Long term:
 nausea Decrease hgb and -demonstrate pain on dorsiflexion of foot, thrombosis (DVT), although After 2weeks of
hct count behaviours and swelling and redness. DVT is often present without
-hgb: 80 g/;L nursing
lifestyle changes to a positive Homan’s sign.
-Hct: 24 vol% intervention goal
improve circulation -measure I&O, nothing -to obtain baseline data
-RBC: 2.65x10 9/L -have normal hgb positive balance –intake in was not met, as
-BUN: 58.5mmol/L Anemia evidence by :
from 80g/L to L to excess output
-creatinine: 1810.0 -review laboratory studies -to determine probability, -laboratory still
135g/L
umol/L such as, hgb/hct, RBC,BUN, location and degree of remain and need
Hct from 24% to
creatinine, and diagnostic important. to be improved
40% , RBC from studies - demonstrate
2.65x10 9/L to 4.5- behaviours and
5.9x10 9L Collaborative: lifestyle changes
Creatinine from Administer ferrous sulphate to improved
1810.0 to 110, BUN + folic acid as prescribed circulation
from 58.5 to 7.2
Assessment Nursing Analysis Planning Intervention Rationale Evaluation
Diagnosis
Subjective: ACTIVITY Decrease oxygen Short term: -monitor vital signs -to reassess vital function Short term:
“nanghihina ako” As INTOLERANCE carrying capacity of Within 6-8hrs of changes After 7hrs of
Hgb
verbalized by the RELATED TO nursing nursing
patient IMBLANCE intervention the -assess patients ability to -influence choice of intervention goal
OXYGEN Decreased patient will: perform ADLs noting interventions or needed was met, as
nutrition in cells assistance
Objective: SUPPLY AND reports of weakness, evidence by:
 weakness DEMAND -verbalize fatigue and difficulty of -the patient,
 fatigue Decreased ATP understanding of accomplishing task verbalized
 pale skin and production since potential loss of understanding of
conjunctiva oxygen is needed ability in relation -promote independence in -mild/moderate activities potential loss of
 chest pain for oxidation of to existing self-care activities as and improve self-esteem ability in relation
Hgb:80g/L condition tolerated are promoted to existing
CHO/glucose
Hct:24 vol% condition
T:37.1 -encourage alternating -minimized exhaustion and
Decreased energy
PR:89bpm Long term: activity with rest helps balance oxygen Long term:
or muscle
RR:17cpm Within 1-2weeks supply and demand after 1week of
weakness
BP:120/80mmHg of nursing nursing
intervention the -enhance lung expansion to interventions,
Activity maximize oxygen for
patient will: -elevate head of the bed as Goal was
intolerance cellular uptake
tolerated partially met, as
-completely -bed rest is maintained to evidence by:
independent on all -explain importance of bed decrease metabolic -the patient
ADLs and without rest demands thus conserving verbalized partial
assistance with the energy dependence on
S/O ADLs with his S/O
such as able to
-have good skin -promote quiet -to promote rest feed himself,
turgor environment assistance in
-have normal toileting and
-to identify the extent of bathing
haemoglobin level -monitor laboratory results
deficiency and for better -demonstrated
from 80 g/L to like hgb and hct treatment plan
135g/L good skin turgor
and well being
Hct from 24% to -encourage to increase -to increase iron
-able to
40% intake of iron-rich foods supplement of the body
participate in
-reports increase self-activities
sense of well (grooming
being dressing)
-hgb and hct still
-is free from needs to be
weakness and risk evaluated
for complications
has been
prevented and will
deliver safely
Assessment Diagnosis Analysis Planning Intervention Rationale Evaluation
Subjective: Ineffective Bacterial/ Viral After 8 hours of Independent: After 8 hours of
“Nahihirapan akong airway clearance invasion nursing -Encourage deep breathing -Deep breathing promotes nursing
huminga” as related to intervention, exercise oxygenation before interventions goal
verbalized by the increased secretions will be controlled coughing partially met, the
patient production of Multiplication of mobilized; airway patient was able
respiratory bacteria/ Virus patency will be to:
Objective: secretions enters the lungs free of secretions, -Assist in patient coughing -To improve productivity -Demonstrate
 Rapid breathing as evidence exercise of the cough coughing and
 Positive patients’ ability to deep breathing
productive Cells in the effectively cough -Monitor rate, rhythm, -Provides a basis for exercise every 1-2
 Crackles immune system and secretions, depth and effort of evaluating adequacy of hours during the
 Dyspnea gathers in lungs to clear lung sounds respirations ventilation day
Vital Signs taken as stop infection and -Respiratory
follows uncompromised -Assist patient into -To promote drainage of crackles can still
T:37.1 Inflammation and respiratory rate. moderate high backrest secretions and better lung be heard at the
PR:89bpm production of position expansion right lower lobe
RR:30cpm secretions increaseLong Term: -Cough continues
Pulmonary Free of infection -Auscultate lung fields, -Decreased airflow occurs to be productive
BP:140/90mmHg infection that may cause of nothing areas of decreased in areas consolidated with
sputum. of absent airflow and fluid. Bronchial breath
Expectorate adventitious breath sound sounds can also occur in
Sputum sputum, relax the consolidated areas
production excess, patient within the
accumulated shift, free of Dependent:
secretions in the shortness of Administer ordered -To help loosen and clear
airways breathing. Patient medications such as the mucus from the
may do the activity mucolytic agents, airways(mucolytic);
Airway Blockage daily living. bronchodilators and decrease resistance in the
expectorant. respiratory airway and
increase airflow to the
lungs