ASSESSMENT

Subjective: Nahapo kag maluya siya sa gihapon, as verbalized by the mother. Objective: Hemoglobin= 56 gms/L RBC count=2.00x10^12/L Hematocrit=0.17 Vol(fr) ESR=147 mm/hr Chest PAL Impression:
Pulmonary Congestion

NURSING DIAGNOSIS
Impaired gas exchange r/t altered oxygencarrying capacity of blood

PLANNING
The patient will demonstrate adequate oxygenation with a respiration of 33 bpm to 12-25 bpm and absence of nasal flaring and suprasternal retractions after one (1) hour of nursing intervention.

INTERVENTION
Independent: 1.)Noted respiratory rate, depth, use of accessory muscles and areas of pallor. To evaluate degree of compromise. 2.) Auscultated lung fields, noting areas of decreased or absent airflow and adventitious breath sounds (crackles and wheezes). Decreased airflow occurs in areas consolidated with fluid. 3.) Elevated head of bed and changed positions every 2 hours or PRN. Promotes optimal chest expansion.

NURSING COMPETENCY

NURSING THEORIES

EVALUATION

Safe & Quality Nursing Care

Safe & Quality Nursing Care

Hyperaerated Lungs Cardiomegaly RR= 33bpm Nasal flaring noted Suprasternal retractions noted Pallor on palms and skin Pale conjunctivae Child is restless.

Safe & Quality Nursing Care

Faye Glenn Abdellahs Typology of 21 Nursing Problems To facilitate the maintenance of a supply of oxygen to all body cells. Cells need oxygen in order to play their vital function as basic unit of life. Any depletion of oxygen may lead to the malfunctioning of cells.

4.)Monitored I&O, limiting intake to not more than 800 mL/day. To prevent hyperviscosity of blood. 5.)Encourage deepbreathing exercises. Promotes optimal chest expansion. 6.)Encouraged adequate rest and limit activities to within patients tolerance. Helps limit oxygen needs and consumption. 7.)Encouraged mother and folks to maintain cleanliness and orderliness of the room to keep environment allergen and pollutant free. To reduce irritant effect of dust and chemicals on airways.

Safe & Quality Nursing Care Virginia Hendersons 14 Basic Needs Henderson identified patients need for : a.)elimination of body wastes; b.)move and maintain comfort c.)sleep and rest

Health Education

Florence Nightingales Environmental Theory Management of She states that Resources & nature or Environment environment allows reparative process to occur or alter to prevent or cure diseases.

Health Education

8.)Emphasized the Communication Florence importance of maintaining Nightingales optimal nutrition by Environmental consuming the meals Theory prepared by the hospitals Nightingale dietary section. addressed the need Improves stamina and to maintain optimal reduced the work of nutrition by eating breathing. appropriately and adequately. Dependent: 1.)Provided supplemental O2 at 1 LPM via nasal cannula. Maximize O2 transport to tissues. 2.)Administered 1 pack RBCs, monitoring closely for transfusion reactions. Increases number of oxygen-carrying cells, dilutes percentage of Hbs, and improves circulation. Legal Responsibility 3Cs of Lydia Hall Care, Core ,Cure The Cure Circle is based in the pathological and therapeutic sciences and is shared with other members of the healthcare team.

Legal Responsibility

ASSESSMENT
Subjective: Daw nabudlayan siya pirmi magginhawa, as verbalized by the mother. Objective: Hemoglobin= 56 gms/L RBC count=2.00x10^12/L Hematocrit=0.17 Vol(fr) ESR=147 mm/hr RR= 33bpm BP=90/50 mmHg Chest PAL Impression:
Pulmonary Congestion

NURSING DIAGNOSIS
Altered Tissue Perfusion r/t decreased hemoglobin concentrations in blood

PLANNING
After two (2) hours of nursing intervention, patient will achieve normal respirations and blood pressure from 33 bpm to 12-25 bpm and from 90/50 mmHg to 105+13(sys) mmHg respectively.

INTERVENTION
Independent: 1.)Assessed hydration status. Dehydration reduces glomerular filtration rate (GFR). 2.)Monitored fluid intake, urine output and weighed daily. To provide non-invasive assessment of cardiovascular and renal function. 3.)Monitored vital signs, especially noting blood pressure changes, including hypertension or hypotension. Any of which places patient at high risk for kidney damage.

NURSING COMPETENCY

NURSING THEORIES

EVALUATION

Safe & Quality Nursing Care

Safe & Quality Nursing Care

Faye Glenn Abdellahs Typology of 21 Nursing Problems Abdellah identified the patients need to: a.)facilitate the maintenance of fluid and electrolyte balance;

Hyperaerated Lungs Cardiomegaly Capillary refill=4 seconds Dysrhythmias noted Nasal flaring noted Suprasternal retractions noted

Safe & Quality Nursing Care

b.)recognize the physiological responses of the body to disease conditions--pathological, physiological, compensatory;

Pallor on palms and skin Pale conjunctivae () facial edema

4.)Provided periods of undisturbed sleep and calming environment. To reduce myocardial workload. 5.)Provided for fluid and diet restriction (not more than 800 mL/day and ) while providing adequate calories and hydration. To meet the bodys need without overtaxing kidney function. 6.)Encouraged mother and folks for regular check-up and laboratory follow-up upon discharged. To provide monitoring and earlier intervention of underlying condition, and to evaluate effectiveness of therapeutic interventions.

Management of Resources & c.)promote optimal Environment activity, exercise, rest and sleep. Safe & Quality Nursing Care Dorothea Orems Self-Care Deficit Theory Orem identifies selfcare requisites as the maintenance of a sufficient intake of water or other fluids. Imogene Kings Goal Attainment Theory King stated that the nurse brings specialized knowledge and skills and can communicate information that is helpful in setting goals.

Health Education Quality Improvement

Dependent: 1.)Provided supplemental O2 at 1 LPM via nasal cannula. To improve tissue perfusion/organ function.

Legal Responsibility

3Cs of Lydia Hall Care, Core ,Cure The Cure Circle is based in the pathological and therapeutic sciences and is shared with other members of the healthcare team.

ASSESSMENT
Subjective: Daw gapanghabok iya itsura, as verbalized by the mother. Objective: RR= 33bpm BP=90/50 mmHg Hemoglobin= 56 gms/L Hematocrit=0.17 Vol(fr) Chest PAL Impression:
Pulmonary Congestion

NURSING DIAGNOSIS
Excess fluid volume r/t excess fluid retention secondary to Acute Poststreptococcal
Glomerulonephritis

PLANNING
After four (4) hours of nursing intervention, patient will have his RR and BP within normal limits.

INTERVENTION
Independent: 1.)Monitored BP and RR every 2 hours. Hypertension and elevated RR may reflect developing/increasing pulmonary congestion.

NURSING COMPETENCY

NURSING THEORIES

EVALUATION

Safe & Quality Nursing Care Jean Watsons Theory of Transpersonal Nursing She identified in her carative factors the need of assisting gratification of basic human needs while preserving human dignity and wholeness.

and its medical therapy

Cardiomegaly Crackles and wheezes on auscultation (+) Grade 3 organic systolic murmur

2.)Closely monitored fluid intake from all sources including p.o.(by mouth) and I.V., limiting fluid intake to not more than 800 ML/day and Na(Sodium) intake of not more than /day. To assess precipitating factors.

Safe & Quality Nursing Care

3.)Monitored urine output, noting amount and color. Urine output may be scanty and concentrated because of reduced renal perfusion.

Safe & Quality Nursing Care

4.)Weighed and recorded patient daily every morning. Provides comparative baseline and evaluates the effectiveness o diuretic therapy.

Record Management

Dorothea Orems Self-Care Deficit Theory Orem identifies selfcare requisites as the provision of care associated with elimination processes and excrements. Florence Nightingales Environmental Theory She also discussed Petty Management, which includes the documentation of plan of care, monitoring of intervention and evaluation of outcomes to ensure continuity.

5.)Placed patient in semifowlers position during rest time. To facilitate movement of diaphragm, thus improving respiratory effort.

Safe & Quality Nursing Care Faye Glenn Abdellahs Typology of 21 Nursing Problems She acknowledged the importance of promoting optimal activity; exercise, rest and sleep and the creation and maintenance of a therapeutic environment.

6.)Promoted early Safe & Quality ambulation and the Nursing Care maintenance of a quiet environment, limiting Management of external stimuli. Resources & To promote Environment mobilization/elimination of excess fluid. Dependent: 1.)Maintained fluid and sodium restrictions as indicated. Reduce total body water/ prevents fluids reaccumulation. Legal Responsibility

3Cs of Lydia Hall The Cure Circle is based in the pathological and therapeutic sciences and is shared with other members of the healthcare team.

2.)Administered Furosemide 7 mg IV, Q12H. A potent loop diuretic inhibiting sodium and chloride reabsorption, leading to a sodium-rich dieresis.

Legal Responsibility

3Cs of Lydia Hall Care, Core ,Cure The Cure Circle is based in the pathological and therapeutic sciences and is shared with other members of the healthcare team.

ASSESSMENT

NURSING DIAGNOSIS

PLANNING

INTERVENTION

NURSING COMPETENCY

NURSING THEORIES

EVALUATION