Treatment/infusion IVF

Classification PNSS TL

Indication Given with patients with electrolyte imbalances and also administer together with the PRBC

Contraindication Contraindicated with patient who is edematous

Nursing responsibility Monitor acid-base imbalances and fluid and electrolytes

CUES
Subjective: - The patient is not interested to have any exercise program. Every time the client walks, he experience severe dizziness. Series of dizziness and headaches were experienced before admission in the hospital. He easily gets tired when he does simple exercise like walking. He is a call center agent; his daily routine is work which requires him to use the computer more frequently from the start until the end of the shift.

NURSING DIAGNOSIS
Risk for Activity Intolerance

ANALYSIS
The client is at risk for activity intolerance for the reason that he has a difficulty of walking, he experiences severe dizziness on daily routine, and history also shows that he has previous history of imbalance. As defined from NANDA 11TH Edition, clients are at risk of experiencing insufficient physiological or psychological energy to endure or complete required or desired daily activities.

Objective:

(+) History of Previous Intolerance The client uses support material / assistive devices while walking. Diagnosis of Vascular Headache ruled out brain occupying lesion

Subjective: - The client doesnt wear his proper eye correctional glasses. The patient was restricted to stay in bed and needs to ask for help to accompany him in the bathroom. Every time the client walks, he experience severe dizziness. Series of dizziness and headaches were experienced before admission in the hospital.

Risk for Falls The client has increased susceptibility to falling that may cause physical harm (NANDA, 11TH EDITION). The patient is experiencing severe dizziness and headache, which results to his use of assistive materials while walking, and doing any other daily routine. Also, the patient was restricted to stay in bed and needs to ask for help to accompany him in the bathroom.

Objective: - Presence of Orthostatic Hypotension The client uses support material / assistive devices while walking. Diagnosis of Vascular Headache ruled out brain occupying lesion, & tension headache

Subjective: - The client was prescribed eye correctional glasses by an optometrist few months ago, but he did not use any or complied with the doctors advice. Every time the client walks, he experience severe dizziness. Series of dizziness and headaches were experienced before admission in the hospital.

Non-compliance ( Use of Correctional Eye Glasses )

The muscles in your eyes are bound to decay over time, and any incorrect lenses can result in developing problems regarding our eyesight. As a result, it is imperative that you should visit your optometrist to ensure your full range of vision and have your eye strength checked. It will lead that youll be a danger to others and to yourself.

Objective: - No presence of eye correctional glasses to adhere with his vision level.