PRINCESS Q PIMENTEL

ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION

BP 180/100 Fluid volume Short Term Assess for cardiac As the level of Short Term
RR 25 excess :After 4-8 hours of Dysrhythmias potassium :The patient shall
PR 112 related to nursing decreases in have
T 38 abnormal interventions, Cushing’s demonstrated
Edema retention of patient will syndrome, behaviors
Weight gain sodium and demonstrate the chances of to monitor fluid
Pulmonary water behaviors to abnormal heart status
congestion monitor fluid status rhythms increases. and reduce
(SOB,DOB) and recurrence of
Oliguria reduce recurrence fluid excess
Distended jugular of fluid Instruct the client This position
vein excess to decreases fluid Long Term
Changes in mental elevate feet when accumulation in the :The patient shall
status sitting down. lower have
Long Term extremities. manifested
:After 3 days of stabilized
nursing fluid volume AEB
intervention the Instruct the client Limiting fluid intake balance
patient to is important I& O, normal VS,
will manifest reduce fluid intake in preventing table
stabilize fluid as circulatory weight, and free
volume AEB indicated. overload. from
balance I & O, signs of edema.
normal VS, stable
weight,
and free from signs Encourage the Too much sodium
of client to in the diet
edema have low sodium promotes fluid
and retention and
high potassium weight gain. There
diet. should be an
adequate
potassium in the
diet
since the elevation
of cortisol
level causes
hypokalemia.

Administer Cortisol and

antihypertensive mineralocorticoid
medications as excess causes
prescribed. increase blood
pressure as a result
of sodium
and water
retention.
 ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION

BP 180/100 Risk For Injury Patient will be free Assess the skin Cushing’s disease Patient verbalized
RR 25 related to of frequently to check causes thinning feelings of
PR 112 generalized fatigue fractures or soft for of the skin because increased
T 38 and tissue reddened areas, cortisol energy and
Edema weakness. injuries. skin causes the improved
Weight gain breakdown, breakdown of well-being.
Pulmonary tearing, or some
congestion Patient will excoriation. dermal proteins
(SOB,DOB) implement along with the Patient
Oliguria measures to weakening of small demonstrates a
Distended jugular prevent injury. blood vessels. more positive and
vein happier attitude
Changes in mental than
status Patient will Assess the client Excessive cortisol before the
Fatigue verbalize for causes interventions
Poor physical increased energy decreased height decreased bone were applied
condition and and formation,
improved well kyphosis (forward increased bone
being rounding of the reabsorption, Patient is able to
back). increased renal identify
calcium factors that
excretion, and aggravate
decreased calcium and relieved her
absorption from fatigue.
the intestines.
These changes can
result in Patient is able to
decreased bone record
density and the aggravating factors
 development of that
osteoporosis. led to determining

Increased cortisol
Ask the client levels increase
about the catabolism of
problems with poor peripheral
wound healing. tissues.

Cushing’s disease is
Discuss with client associated
safety measures for with loss of bone
ambulation and density and
daily development of
activities. osteoporosis.
The client is at risk
for
pathological
fractures as a result
of minor stress on
the weaker
bones.

Eating a high-
Encourage the protein diet can
client to help prevent the
eat a high-protein muscle loss
diet associated with
 Cushing
syndrome.

Subjective Data: Imbalance Patient’s nutritional Assess appetite and Assess appetite and Following
 Fatigue nutrition: less status for for the treatment
 Lower back / leg than body is optimized as the presence of presence of patient is Alert and
pain requirement evidenced nausea, nausea, oriented, and
 Abdominal pain by maintenance of vomiting, or vomiting, or anxious to
 Irritability / weight diarrhea. diarrhea. learn to care for
depression and adequate himself at
 Reports dietary home. After dietary
significant intake. Monitor trends in This provides instructions and
weight loss weight. documentation of teaching for self-
Objective Data: weight care that
BP 100/80 loss trends. patient verbalizes
PR 97 an understanding
RR 18 of illness
T 36.7 Assess foods that Appetite may and the need to
patient increase with take his
can tolerate. preferred and medication
tolerable carefully and
foods. accurately. A
referral is
made to a social
Monitor serum Patients with worker
glucose adrenal for assistance with
levels. insufficiency are costs of
likely to medications.
experience
hypoglycemia.

Assess for salt Aldosterone

cravings. deficiency
causes increased
renal
excretion of
 sodium.

Encourage rest This is important to

periods facilitate
after eating. digestion.

Keep a late- In case the patient

morning becomes
snack available. hypoglycemic
Dry oral mucous Deficient Fluid Patient will Encourage oral Necessary to After 12 hours of
membrane Volume experience fluids prevent fluid nursing
Body weakness related to adequate fluid as the patient volume deficit intervention, no
Poor skin turgor hypovolemia volume and tolerates because the signs of
Dizziness secondary to electrolyte balance kidneys are unable hypovolemic shock
Disorientation adrenal as to conserve and
BP 99/44 insufficiency evidenced by urine sodium that the mucosa of
PR 90 output the
RR 18 greater that 30 patient was moist,
T 36.7 mL/hr. Instruct the patient Sweating increases and
to sodium loss urine output is
ingest salt additives greater
in than 30 mL/hr.
conditions of
excess
heat or humidity

Monitor and Decrease in

document vital circulating blood
signs volume can cause
especially BP and hypotension
HR. and tachycardia.

Assess color and A normal urine

amount of urine. output is
Report urine considered normal
output not less than
less than 30 ml/hr 30ml/hour.
for Concentrated urine
2 consecutive denotes fluid
hours. deficit.

Urge the patient to Oral fluid

drink prescribed replacement is
amount of fluid. indicated for mild
fluid deficit
and is a cost-
effective method
for replacement
treatment.

Emphasize Attention to mouth

importance of oral care
hygiene. promotes interest
in drinking
and reduces
discomfort of dry
mucous
membranes

Provide Drop situations

comfortable where patient
environment by can experience
covering patient overheating to
with prevent further
light sheets. fluid loss.
PR 85 bpm Impaired tissue Patient achieves Assess skin warmth Peripheral After 8 hours of
RR 30 bpm perfusion: adequate and vasoconstriction nursing
BP 160/100mmHg cardiovascular cardiac output (CO) peripheral pulses. causes cool, pale, interventions,
Cyanotic lips related to as diaphoretic patient was
Pale conjunctiva adrenal evidenced by skin. able to
and nail insufficiency strong demonstrate
beds peripheral pulses, behaviors to
Weak peripheral normal Monitor vital signs Sudden improve
pulses vital signs, urine with development of circulation
Cold clammy skin output frequent profound
Dry, scaly skin greater than 30 monitoring of hypotension may
Decreased skin mL/hr, BP. Include indicate Addisonian
turgor >4 warm and dry skin, assessment crisis.
seconds and for orthostatic Auscultatory BP
Decrease capillary alert responsive hypotension. may be
refill mentation. Anticipate unreliable
4seconds direct intra-arterial secondary to
monitoring of vasoconstriction.
pressure
for a continuing
shock
state.

Monitor urine Oliguria is a classic

output. sign of
inadequate renal
perfusion.

The patient will

Monitor oxygen have
saturation through decreased oxygen
pulse saturation.
oximetry or arterial
blood gas results,
as
appropriate.

The patient’s
Minimize stressful normal
situations and response to stress
promote a is not
quiet environment. functioning
Promote bed rest. because he or
she cannot produce
corticosteroids.
Stress can
result in a life-
threatening
situation with
Addisonian
crisis.
Generalized edema Fluid volume After 8 hours of Assess vital signs A BP drop of more
Difficulty of excess nursing Assess color, than 15
breathing related to adrenal intervention ,the concentration, and mm Hg when
shortness of insufficiency patient amount of urine. changing from
breath shall demonstrate Encourage oral supine to sitting
BP-150/80 mmHg behaviors to fluids as position,
T-37 monitor fluid the patient with a concurrent
PR-81 status and reduce tolerates. elevation
RR-26 recurrence of fluid Instruct the patient of 15 beats per min
excess to in HR,
After 24-48 hours ingest salt additives indicates reduced
of in circulating
nursing conditions of fluids.
intervention, the excess heat Urine volume will
patient will or humidity. decrease,
Manifest Stabilize Refer or admit the urine specific
fluid patient to an acute gravity will
volume AEB care increase, and color
balance I & O, setting. will be
normal VS, stable Explain lifelong darker.
weight steroid Encourage oral
,and free from therapy is fluids as the
signs of necessary patient tolerates.
edema. Administer Sweating increases
parenteral sodium
fluids as prescribed. loss.
Immediate hospital
admission and
treatment are
needed because of
the high
mortality with
Addisonian
crisis.
Patient will need to
take daily
medication to
replace the
lost hormones
Normal saline is
infused
initially to restore
fluid
volume.