Excess Fluid Volume Increased Isotonic Fluid Retention

Assessment S> nahihirapan akong huminga as verbalized by the patient O> Edema Intake exceeds output. Adventitious breath sounds S3 heart sound Pulmonary congestion Change in mental status Diagnosis Planning Intervention Rationale Excess fluid volume n/t W/in 2-30 of nursing Note presence Nursing Priority excess sodium intake intervention the of medical #2 AMB edema, intake client will be able conditions/situat excess outputs, to: ions that adventitious breath potentate fluid sounds, S3 heart Stabilized fluid excess. sound, pulmonary volume as Note amount Nursing Priority congestion, change in evidenced by /rate of fluid #1 mental status balance I/O, intake from all vital signs with sources: PO, in clients normal IV, ventilator limits, stable and so forth. weight, and free Review intake Nursing priority of signs of of sodium and #2 edema. protein Verbalize Osculate breath For presence of understanding sounds crackles of individual /congestion dietary/fluid restrictions. Evaluate For confusion, Demonstrate mentation personality behavior to change. monitor fluid status and Elevate To reduce reduce edematous tissue presence recurrence of extremities and risk of skin fluid excess. change position breakdown frequently Measure abdominal girth. For changes that may Evaluation Was the client able to Stabilize fluid volume as evidenced by balanced I/O vital signs, within clients normal limits, stable weight and free of sign of edema. Verbalized understanding of individual dietary/fluid restrictions. Demonstrate behaviors to monitor fluid status and reduce recurrence of fluid excess. Yes ___ No ____ Goals met ____ Partially met ____ Not met ____

indicate increasing fluid retention/edema

Ineffective Infant Feeding Pattern Impaired ability of an Infant to suck or coordinate the suck/swallow response
Assessment S> Hindi po dumedede ang aking baby as verbalized by the mother. O> Inability to initiate/sustain an effective suck >Inability to coordinate sucking, swallowing, and breathing. Diagnosis Ineffective Infant feeding pattern r/t prematurity and oral hypersensitivity AMB, inability to initiate/sustain an effective suck, Inability to coordinate sucking, swallowing, and breathing. Planning W/in 12O of nursing intervention the client will be able to: Intervention Assess infants suck, swallow and gag reflexes Display Determine level adequate output of as measured by consciousness, sufficient neurological number of wet impairment, diapers daily. seizure activity, Demonstrate presence of appropriate pain weight gain. Compare birth Be free of and correct aspiration. weight/length measurements. Assess sign of stress when feeding. Determine appropriate method for feeding (e.g. special nipple/feeding device, gavage/enteral tube feeding) and choice of breast milk/formula to Rationale Provides comparative Nursing priority #1 Evaluation Was the client able to: Display adequate output as measured by sufficient number of wet diapers. Demonstrate appropriate weight gain. Be free from aspiration Yes ___ No ____ Goals met ____ Partially met ____ Not met ____

Nursing priority #1 Nursing priority #1 Nursing priority #2

meet infants needs Limit duration of feeding to maximum of 30 minutes based on infants response (e.g. signs of fatigue) Refer mother to lactation specialist for assistance and support in dealing of unsolved issues.

To balance energy expenditure with nutrient intake. Nursing priority #2

Risk for Impaired Liver Function At risk for liver dysfunction

Assessment S> Diagnosis Risk for Impaired Liver dysfunction r/t unknown etiology Planning Intervention W/in 2-3O of nursing Assess for intervention the client exposure to will be able to: contaminated Demonstrate food or poor behaviors sanitation lifestyle practices by changes to food service reduce risk workers factors and Educate client protect self from on way(s) to injury. prevent Be free of signs exposure. of liver failure as evidenced by liver function studies w/in Assist with normal levels medical and absence of treatment of jaundice hepatic underlying enlargement or condition altered mental status. Encourage the client with liver dysfunction to avoid fatty foods, fat interferes with normal function of livercells and can cause additional Rationale Poses risk for exposure to entric viruses (hepatitis A and B) Evaluation Was the patient able to: Demonstrate behaviors, lifestyle changes to reduce risk factors and protect self from injury. Free of signs of liver failure as evidenced by liver function studies with in normal levels and absence of jaundice hepatic enlargement or altered mental status. Yes ___ No ____ Goals met ____ Partially met ____ Not met ____

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To reduced incidenced of HBV and HCB infections/limit damage liver To support organ function and minimize liver damage Nursing priority #2

damage/perma nent scarring to livercells when they can no longer regenerate.

Risk for Constipation At risk for decrease in normal frequency of defecation accompanied by difficult or incomplete passage of stool and/or excessively large, dry stool.
Assessment S> Diagnosis Planning Risk for constipation r/t W/in 2-5Oof the client unknown etiology will be able to: Maintain usual pattern of bowel functioning Demonstrate behaviors or lifestyle changes to prevent developing problem. Intervention Rationale Discuss usual Nursing Priority elimination #1 pattern and use of laxatives. Evaluate Nursing Priority current dietary #1 fluid intake and implications for effect on bowel function Promote Promote soft adequate fluid stool and intake, including stimulate bowel water and high activity fiber fruit juices, also suggest drinking warm fluids Encourage To stimulates activity contractions of exercises with the intestines in limits of individual ability Discuss May help Physiology and reduce acceptable concerns/anxiet variations in y about elimination situation. Evaluation Was the client able to: Maintain usual pattern of bowel functioning Demonstrate behaviors of lifestyle changes to prevent developing problem Yes ___ No ____ Goals met ____ Partially met ____ Not met ____

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 Encourage client to maintain elimination diary, if appropriate

To help monitor bowel pattern.

Delayed Surgical Recovery Extension of the number of postoperative days required to initiate and perform activities that maintain life, health, and well being.
Assessment S> Nahihirapan akong gumalaw, ang sakit ng katawan ko as verbalized by the patient. O> Evidence of interrupted healing of surgical area. Difficulty in moving about required help to complete self care. Diagnosis Delayed surgical recovery r/t extensive/prolonged surgical procedures pain and postoperative surgical site infection AMB evidence of interrupted healing of surgical area, and difficult in moving about requires help to complete self care. Planning W/in 12O of nursing intervention the client will be able to: Display complete healing of surgical area. Be able to perform desired self care activities Intervention Determine extent of surgical involvement of organs/tissues, age/developme nt state of health Assess nutritional status and current intake Determine cultural expectations regarding recovery process and participation of client/others. Note length of hospitalization and progress and compare with expectation for procedures and situation. Recommend Rationale To provide anticipatory guidance in postoperative care Evaluation Was the client able to: Display complete healing of surgical area Able to perform desired self care activities. Yes ___ No ____ Goals met ____ Partially met ____ Not met ____

To determine if nutrition is adequate to support healing Nursing Priority #1

Nursing Priority #3

To reduce

alternating activity with adequate rest periods.

fatigue

Ineffective airway clearance - Inability to clear secretions or obstruction from the respiratory tract to maintain a clear airway.
Assessment S> Nahihirapan akong huminga as verbalized by the patient. Diagnosis Ineffective airway clearance r/t excessive mucus secretions AMB adventitious breath O> Diminished/ sounds, changes adventitious breath respiratory rate, sounds Difficulty vocalizing, Changes in respiratory wide eyed. rate Difficulty in vocalizing Wide - eyed Planning Intervention Rationale O W/in 6 of nursing Monitor Indicative of intervention the client respirations and respiratory will be able to: breath sounds, distress and or Maintain airway nothing rate accumulation of patency. and sounds secretions. (tachypsia Expectorate/clear stridor, secretions crackles, readily wheezes) Demonstrate Evaluate clients To determine absence/reductio cough/ gag ability to protect n of congestion reflexes and own airway. w/breath sounds, swallowing clear, respiration, ability noiseless, improved oxygen Suction To clear airway exchange. nasal/tracheal/ when excessive oral pan or viscous Demonstrate secretions are behavior to blocking airway improved or or client is maintain clear unable to airway. swallow or cough effectively. Encourage deep breathing and coughing exercises; splint To maximize effort. Evaluation Was the client able to: Maintain airway patency. Expectorate/clear secretions readily Demonstrate able/reduction of congestion, with breath sounds clear, respiration, noiseless, improved oxygen exchange. Demonstrate behaviors to improved or maintain clear airway. Yes ___ No ____ Goals met ____ Partially met ____ Not met ____

chest/incision Increased fluid intake. Hydration can help liquefy viscous secretions and improve secretion clearance. To ascertain status and note progress

Ausculate breath sounds and assess air movement.

Risk for Sudden Infant Death Syndrome Presence of risk factors for sudden death of an infants under 1 year of age
Assessment S> Diagnosis Risk for sudden Infant Death Syndrome r/t unknown etiology Planning W/in one day of nursing intervention the patient will be able to: Verbalize understanding of modifiable factors Make changes in environment to reduce risk of death occurring from the other factors Fallow medically recommended prenatal and postnatal care. Intervention Identify individual factors pertaining to situation. Rationale To determine modifiable or potentially modifiable factors that can be addressed and treated. SIDS is the most common cause of un explained death between the 2nd and 4th mos. Smoking is known to negatively affect the fetus prenatally as well as after birth some reports indicate an increased risk of SIDS in babies of smoking mothers. Research confirms that fever infants die of SIDS when Evaluation Was the client able to: Verbalize understanding of modifiable factors Make changes in environment to reduce risk of death occurring from the other factors. Follow medically recommended prenatal and postnatal care Yes ___ No ____ Goals met ____ Partially met ____ Not met ____

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Note whether mother smoke during pregnancy or is currently smoking

Recommend that infant most be placed on his or her back

to sleep, both at night time and naptime. Disease known facts about SIDS w/ parents.

they sleep on their backs and that a side lying position is not to be used. Correct misconceptions and help reduce level of anxiety.

Deficient Knowledge Absence of deficiency of cognitive information related to specific topic (lack of specific information necessary for clients /so(s) to make informed choices regarding condition/treatment/lifestyle changes.)
Assessment S> I dont want to learn and I dont have any idea from what is it as verbalized by the patient O> Inaccurate follow- through of instruction/ performance of test Inappropriate/ exaggerated behaviors. Diagnosis Deficient knowledge r/t unfamiliarity w/in info. Resources and lack of interest in learning AMB Inaccurate follow through instruction/ performance of test Inappropriate / exaggerate behaviors Planning With in 12O of nursing intervention the client will be able to Participate in learning process and exhibit increased Interest and also perform necessary procedures correctly and explain reasons for action. Intervention Ascertain level of knowledge, including anticipatory needs Determine clients ability / rediness and barriers to learning. Determine the blocks of learning Provide environment that is conducive to learning Provide info about additional learning resources Rationale Nursing Priority #1 Evaluation Was the client able to: Participate in learning process. Exhibit increased interest and also perform necessary procedures correctly and explain reasons for action. Yes ___ No ____ Goals met ____ Partially met ____ Not met ____

Individual may not be physically, emotionally or mentally capable at this time. Nursing Priority #2 Nursing Priority #8

May assist with further learning/ promote learning at own pace.

Death Anxiety Vague uneasy feeling of discomfort or dread generated by perception of a real or imagined threat to ones existence.
Assessment S> Ayokong mamatay as verbalized by the patient. Diagnosis Death anxiety r/t confronting reality of terminal disease and uncertainty of prognosis AMB Ayokong mamatay as verbalized by the patient. Planning Intervention Rationale O With in 2 - 3 of Determine how Nursing Priority nursing intervention client sees self #1 the client will be able in usual lifestyle to role functioning Identify and and perception express feelings and meaning of freely / anticipated loss effectively to him or her and SO(s) Look toward / plan for the Ascertain To identify future one day correct misconceptions, at a time. knowledge of lack of info, situation other pertinent Formulate a issues plan dealing with individual concerns and Provide open Nursing Priority eventualities of and trusting #2 dying as relationship appropriate. Encourage Enhance trust expression of and therapeutic feelings. relationship. Acknowledge anxiety/fear. Do not deny or reassure client that everything will be all right. Be honest when Evaluation Was the client able to: Identify and express feelings freely/ effectively Look toward/plan for the future one day at a time. Formulate a plan dealing w/ individual concerns and eventually of dying as appropriate. Yes ___ No ____ Goals met ____ Partially met ____ Not met ____

answering question / providing information Provide calm peaceful setting and privacy as appropriate.

Promotes relaxation and ability to deal with situation.

Risk for Situational Low Self Esteem At risk for developing negative perception of self worth in response to a correct situation (Specify)
Assessment S> Diagnosis Risk for situational low self esteem r/t behavior inconsistent with values and lack of recognition; AMB loss of self confidence. Planning With in 12O of nursing intervention the client will be able to: Acknowledge factors that lead to possibility of feelings of low self esteem. Verbalize view of self as worthwhile, important person who functions well both interpersonally and occupationally. Demonstrate self confidence by setting realistic goals and actively participating in life situation Intervention Identify clients basis sense of self worth and image clients has of self existential physical, psychological. Determine client awareness of own responsibility for dealing w/situation personal / growth and so forth. Verify clients concept of self in relation to cultural/religious ideals. Rationale Nursing Priority #1 Evaluation Was the client able to: Acknowledge factor that lead to possibility of feelings of low self esteem. Verbalized view of self as a worthwhile important person who functions well both interpersonally and occupationally. Demonstrate self confidence by selling realistic goals and actively participating in life situation. Conflict between correct situation and these ideals may contribute to risk of low self esteem. Yes ___ No ____ Goals met ____ Partially met ____ Not met ____

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Nursing Priority #1

Rediness for Enhanced Communication a pattern of exchanging information and ideas with others that is sufficient for meeting ones need and life goals, and can be strengthened.
Assessment S> I was worthless, I may not existing. O> Able to speak/ or write a language Forms a words, phrases, sentences. Uses/ interprets non verbal cues appropriately Diagnosis Rediness for enhanced communication r/t unknown etiology. Planning With in 2-3O of nursing client will be able to: Verbalize or indicate an understanding of the communication process Identify ways to improve communication. Intervention Rationale Ascertain Many factors circumstances are involved that result in communication clients desire to and identifying improve specific communication. needs/expectati ons helps in developing realistic goals and determining likelihood of success. Evaluate mental Disorientation status and psychotic conditions may be affecting speech and the communication of thoughts, needs and desires. Determine Concerns about comfort level in language skills expression of can impact feelings and perception of concepts in own ability to nonproficient communication. language. Evaluation Was the client able to: Verbalize or indicate an understanding of the communication process. Identify ways to improve communication. Yes ___ No ____ Goals met ____ Partially met ____ Not met ____

 Evaluate congruency of verbal and nonverbal messages. Pay attention to speaker. Be an active listener.

Communication is enhanced when verbal and nonverbal messages are congruent. The use of actives-listening communicates acceptance and respect for the client, establishing trust and promoting openers and honest expressions. It communicate that the belief of the client is a capable and competent person.

Rape - Trauma Syndrome Sustained maladaptive response to a force violent sexual penetration against the victims will and consent (rape is not a sexual crime, but a crime of violence and identified as sexual assault. Although attacks are most often directed toward women, men also may be victims.)
Assessment S> I feel embarrass and I want to kill my self, as verbalized by the patient O>Physical trauma Confusion Agitation Mood swings Suicide attempts Dissocative disorders Diagnosis Rape Trauma Syndrome r/t emotional reactions AMB Physicall trauma, confusion, agitation, mood swings, suicide attempts, dissociative disorders. Planning Intervention Rationale With in 1 week of Observe for and Nursing Priority nursing intervention elicit information #1 the client will be able about physical to: injury and Deal assess stress appropriately related with emotional symptoms, such reactions as as numbness, evidenced by headache behavior and tightness in expression of chest, nausea, feelings. pounding heart and so forth. Report of absence of Provide May indicate physical psychological silence reaction. complications support by pain, and listening and discomfort. remaining with the client does Verbalize not want to positive self take, accept image. silence. Verbalize Identify support The client recognition that persons for this partner can be incident was not individual. important to her of own doing. or his recovery Demonstrate by being patient appropriate and confronting Evaluation Was the client able to: Deal appropriately with emotional reactions as evidenced by behavior and expression feelings. Report of absence of physical complications, pain and discomfort. Verbalize positive self image Verbalize recognition that incident was not of own doing. Demonstrate appropriate changes in lifestyle as necessary and seek/obtain support from SO(s) as needed. Yes ___ No ____ Goals met ____ Partially met ____ Not met ____

changes in lifestyle (e.g., change in job/residence) as necessary and seek/obtain support from SO (s) as needed.

Allow the client to work through own kind adjustment. May be withdrawn or unwilling to talk; do not force the issue, but be available if needed.

when partners talk through the incident, the relationship can be strengthened. Nursing Priority #2

Rediness for Enhanced Coping A pattern of cognitive and behavioral efforts to manage demands that is sufficient for well being and can be sthrengthened.
Assessment S> I was so stress, hindi ko na alam gagawin ko as verbalized by the patient O>Uses a broad range of problem/ emotional oriented strategies > uses spiritual resources. Diagnosis Rediness for enhanced coping r/t unknown etiology AMB uses a broad range of problem/emotional oriented strategies, uses spiritual resources. Planning With in 2 5O of nursing intervention the client will be able to: Assess current situation accurately. Identify effective coping behaviors currently being used Verbalize feeling congruent with behavior. Intervention Evaluate ability to understand events, provide realistic appraisal of situation Rationale Provides info. About clients perception, cognitive, ability, and whether the clients is aware of the facts of the situation. This is essential for planning care. Accurate identification of situation that client is dealing with provides info. For planning interventions to enhance coping abilities. An individual program of relaxation, meditation, involvement Evaluation Was the client able to: Assess current situation accurately Identify effective coping behaviors currently being used. Verbalized feeling congruent with behaviors. Yes ___ No ____ Goals met ____ Partially met ____ Not met ____

Determine stresses that are currently affecting client.

Encourage client to create stress management program.

with caring for others/pets will enhanced coping skills and strengthen client ability to manage challenging situation.

Risk for Impaired religiosity At risk for an impaired ability to exercise reliance on religious beliefs and /on participate in rituals of a particular faith tradition.
Assessment S> Diagnosis Risk for Impaired religiosity r/t unknown etiology Planning With in 1 day of nursing interventions the client will be able to: Express understanding of relation of situation/health status to thoughts and feelings of concerns about ability to participate in desired religious activity. Intervention Rationale Determine Nursing Priority clients usual #1 religious/spiritua l beliefs, past or current involvement in specific church activities. Assess lack of transportation/ environmental barriers to participation in desired religious activities. Have client identify and prioritize current/ immediate needs. Nursing Priority #2 Evaluation Was the client able to: Express understanding of relationship of situational health status to thoughts and feelings of concerns. About to participate in desired religious activities. Yes ___ No ____ Goals met ____ Partially met ____ Not met ____

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Dealing with current need is easier than trying to predict the future.

NONCOMPLIANCE Behavior of person and/or caregiver that fails to concede with a health promoting or therapeutic plan agreed on by the person (and/or the family and/or the community) And healthcare professional. In the presence of an agreed on health promoting or therapeutic plan, persons or caregiver behavior is fully or partially non adherent and may lead to clinically or ineffective or partially outcomes.
Assessment S> Nahihirapan po akong magtrabaho pati na rin sa pagdedesisyon as verbalized by the patient. O> Behavior indicative of failure to adhere Failure to progress Failure to keep appointments. Diagnosis Noncompliance r/t personal/developmental abilities AMB behavior indicative of failure to adhere, failure to progress and failure to keep appointments. Planning With in one day of nursing interventions the client will be able to: Verbalize accurate knowledge of condition and understanding of treatment regimen. Verbalize commitment to mutually agreed upon goals and treatment plan Demonstrate progress towards desired outcomes/ goals. Intervention Provide for continuity of care in and out of the hospital / care setting including long range plans. Provide information and help client to know where and how to find it on own. Accept the client choice /point of view even if it appears to be self destructive. Avoid confrontation regarding beliefs. Rationale To supports trust facilitate progress towards goals. Evaluation Was the client able to: Verbalize accurate knowledge of condition and understanding of treatment regimen. Verbalize commitment to mutually agreed upon goals and treatment plan Demonstrate progress towards desired outcomes /goals Yes ___ No ____ Goals met ____ Partially met ____ Not met ____

To promote independence and encourage informed decision making To maintain open communication

Nursing Priority #1

 Determine social characteristics, demographic and educational factors, as well as personality of the client.