NURSING CARE PLAN Dat e M A Y Assessme nt S/O: Water y,loose stool(6x/d ay) in mod.

. amt Vomited 5x/shift with sticky vomitus in scanty amount Sunken fontanel noted Sunken eyeballs Need Nursing Diagnosis Objectiv e of Care Nursing Intervention Evaluation

, 2 0 0 7 7am 3pm

Fluid volume Within 2 Maintained deficit r/t days of accurate Intake and h severe providing Output y dehydration nursing -patient may to consider care, will s reduce fluid intake electrolyte maintain during periods of i imbalance fluid and crisis because of 2 Acute electroly o malaise, Gastroenterit tes l anorexia,and so on. is volume o at a Monitored Rationale: functiona v/s,comparing with g l level as patients normal/ Acute i Gastroenterit evidence previous readings d by: c is is an - reduction of inflammation - will Fluids & circulating blood on the defecate volume can occur Electroly stomach & GI semites

After 8 hrs of nursing care, GOAL PARTIALLY MET Patient regained and maintained fluid volume at a functional level as evidenced by: BP=110/70mmHg PR=96bpm Urine Output= 30cc/hr

noted Dry lips & mucus membrane noted. Distended abdomen noted Poor sucking noted Delayed capillary refill noted Pale skin Wt=5.2kgs . FFP @ 78ccx 4 hrs x 3 cycles.

tract which is manifested by diarrhea, abdominal pain associated with nausea, vomiting, fever, and abdominal distention& excessive elimination of waste caused electrolyte imbalance

formed stool at lest 2 times a day

from fluid loss resulting in hypotension and tachycardia

Reference: Medical

Observed for fever, - there changes in will be LOC,skin turgor, decrease dryness of skin and occurren mucous ce of membranes, pain. vomiting - symptoms at least reflective of DHN/ 12 times hemoconcentration a day with consequent - will vasoocclusive state. manifest Monitored v/s moist closely during lips and blood transfusions mucous and noted membra presence of nes and dyspnea, capillary

With serial # 111-0613473 type B+ Serum Na=130.4 mEq Serum Ca= 0.84mEq

Serum K=3.15 mEq

Surgical Nsg. refill in crackles,ronchi,wh th 10 Ed by 2-3 eezes, diminished Brunners & seconds breath sounds Suddarth cough and - weight cyanosis. of 5.2 kgs will - patients heart may increase be already to 5.7 weakened and kgs prone to failure due to chronic - fever demands,placed will on it by the subside anemic state. with the Heart may be temperat unable to tolerate ure of the added fluid less than volume from the 37.5 transfusions or rapid IV fluid administered to heart crisis/shock Administered fluids

as indicated - replaces losses/deficits. Fluids must be given immediately to decrease hemoconcentration and prevent further interaction

Dat e A P R I

Assessme nt Subjective: Dili man ko ganahan mulihok ky dali ra man ko kapuyon,

Need

Nursing Diagnosis

Objectiv e of Care

Nursing Intervention Assessed the degree of dehydration. - to provide baseline information.

Evaluation

Safety

Activity Within 8 Intolerance hrs of r/t nurseimbalance patient between O2 interacti supply and on, will demand 2 demonst

After 2 days of providing nursing care, GOAL PARTIALLY MET As evidenced by:

L 3 0, 2 0 0 7 3 11pm

as verbalized. Objective: Pale lips Tachycardi a (PR=101b pm)

O2 inhalation @ 5L/min via nasal cannula Weakness, body malaise,fat igue

Hemoglobi n Mass Concentrat ion= 20.

rate a in Security physiolo Rationale: gic signs Hypovolemi of c shock intoleran results ce as Energy from loss of evidence fluids & Mgt. d by: occurs more -PR,RR, rapidly & BP will than fluid remain intake within which results to normal the ranges imbalance of O2 supply and decrease demand to in the body. fatigue This oftenly causes -increase fatigue 7 ability to weakness

&

Hypovolemi c shock

Established a 24 hour fluids and - defecated semi-solid stools electrolytes replacement needs at lest 2 times a day and routes (IV,PO) - vomited at least twice a to be used. day. - prevents peak/valleys in fluid - manifested moist lips and level. mucous membranes and capillary refill of at least 2-3 Administered IV fluids as indicated seconds.. and regulated well at prescribed rate. - to correct fluid losses. Administered one unit fresh frozen plasma. - to replace electrolyte losses. provided nutritious - weight increased to 5.5 kgs from 5.2 kgs - fever subsided with a temperature of

 BP=80/60 mmHg RR=28cpm

which can interfere with the individuals ability to work. Reference: Medical Surgical Nsg. 10th Ed by Brunners & Suddarth

participa te in activities , such as personal hygiene & nail care.

diet via NGT. - to meet the bodys nutrient requirements. administered antiinfective as ordered by the physician. - prevents the spread of enteropathogen Encougaged to properly sterilize water. -inhibits the growth of microorganism. Monitored the I & O, and weight everyday. - to assess the fluid

level. Administered Paracetamol for fever as ordered. - to lower down doy temperature to normal range. Instructed watcher to perform TSB. - provide comfort an lowered body temperature.

Dat e A P R

Assessme nt Risk Factors: Decreased hemoglobi

Need

Nursing Diagnosis Risk for Infection r/t inadequate secondary

Objective of Care Within 8 hrs of nursepatient

Nursing Intervention

Evaluation

After 8 hrs of nursing care, Washed hands before & after each GOAL MET care activity , even if sterile gloves were Patient was able to identify

I L 3 0, 2 0 0 7 3 11pm

n (20gm/dL)

Safety &

Invasive procedures Security Rationale: such as Aplastic foley anemia catheter makes one insertion, blood Infection susceptible to transfusion Protectio complicatio , and ns on starting n RBCs, double IV WBCs & lines platelets Objective: which gives high risk Febrile @ for 37.8C infection. Not taken WBC, in a bath for particular, 2 days fights against Untrimmed foreign fingernails substances that enters

defenses 2 Aplastic Anemia

interactio n, will participat e on interventi ons to prevent/ reduce risk of infection as evidenced by: - Body temperatu re will be within normal ranges

used -Reduces risk of cross contamination

interventions to prevent or reduce risk of infection as evidenced by: -Body temperature down to 37C

Inspected wounds/site of -kinahanglan jud d I na invasive devices limpyo pirmi atong lawas, daily, paying particular attention as verbalized. to parenteral nutrition lines. Noted signs of local inflammation/infect ion.

- May provide portal of entry for infection, primary infecting organisms,as well as early identification of secondary verbalizati infections. on of Noted signs and

the body.

Reference: Medical Surgical Nsg. 10th Ed by Brunners & Suddarth

understan ding on proper hygiene

symptoms of sepsis (systemic infection): fever, altered LOC. -To assess causative/ contributing factors

Monitored temperature trends. -fever (38.5C 40C) is the result of endotoxin effect on the hypothalamus and pyrogenreleased endorphins Instructed and

educated to participate in hygienic care - facilitate in promoting personal wellness

NURSING MANAGEMENT a. Nursing Care Plan Ineffective Tissue Perfusion related to decrease in hemoglobin count CUES NURSING SCIENTIFIC OBJECTIVE NURSING DIAGNOSIS EXPLANATION INTERVENTIO N S= Ineffective Acute Short term: tissue glomerulonep After 4 hrs of - Establish O = the perfusion hritis is an nursing rapport patient related to inflammation interventions manifested: decrease in of the the patient Monitor hemoglobin glomerular will be able and record - Low count (56) capillaries. to verbalize VS Because of understandin hgb count RATIONALE DESIRED OUTCOME

Short term: -To gain The patient shall have trust and verbalized understanding of cooperation condition and therapy regimen after 4 hours of -To have a nursing interventions baseline data Long Term:

(56) - Low hematocri t count ( .17) - Palene ss - Pale Palpebral conjuncti va - Body weakness - Restles sness - Cold and clammy skin The patient may manifest - Bronch ospasm

this inflammation the blood vessels, the kidney cannot adequately produce erythropoietin that leads to decrease in hgb and hct count, thus resulting to anemia. Because of this, the patient manifested pale palpebral conjunctiva and paleness. Then the oxygen being supplied in the body is not enough

g of -Assess pt. condition and gen. -To have therapy condition baseline regimen data and note any abnormal Long Term: findings After 5 days -Encourage of nursing quiet, restful -To conserve interventions atmosphere energy/lowe the patient r tissue will be able oxygen to -Encourage demands demonstrate early increased ambulation -To enhance perfusion as once venous individually tolerated return appropriate -Discourage sitting/stand -To improve ing for long and periods, facilitates wearing good constrictive circulation clothing, crossing legs

The patient shall have demonstrated increased perfusion as individually appropriate after 5 days of nursing interventions

- Dysrhyt hmias - Capilla ry refill longer than 3 secs - Use of accessory muscle in breathing - Nasal flaring

due to decrease production of RBC by the kidney which are responsible for the oxygenation of tissues thus leading to ineffective tissue perfusion.

- Check for calf tenderness -May indicate thrombus Elevate formation head of bed especially at -To increase night gravitational blood flow -Instruct to avoid strenuous -To conserve activity energy - Restrict sodium, fluid -To decrease and fat excess fluid intake as volume indicated - Instruct patients SO about food rich in iron -To increase hgb count

-Regulate IVF As ordered -Promote adequate bed rest - Attend needs -Administer meds as ordered

-To maintain hydration -To promote wellness -To promote health -To promote recovery

Activity Intolerance related to muscle weakness ASSESSMEN T S= NURSING DIAGNOSI S SCIENTIFIC EXPLANATION Activity intolerance is insufficient physiological or psychological energy to endure or complete required or desired daily activities. This is present for patient with AGN because patient with such condition can have decrease erythropoietin production since OBJECTIVES INTERVENTIO N -Establish rapport RATIONALE EXPECTED OUTCOME

Activity Intoleran O = Patient ce manifested related the to muscle following: weakness aeb - body physical weaknes inactivity , Low hgb s - restle count (56) ssness - physic Low hematocr al inactivit it count ( .17) y Pale - Low palpebral hgb conjuncti count va (56)

Short Term: After 4 hours of nursing intervention s, the patient will be able to verbalize understandi ng of the causative factors and necessary intervention s. Long Term: After 3 days of

- To obtain patients cooperation - To obtain baseline data -To identify contributing factors -To know the appropriate activity level

-Monitor and record VS -Note patients report of weakness, fatigue and pain

Short Term: The patient shall have verbalized understanding of the causative factors and necessary interventions after 4 hours of nursing interventions. Long Term: The patient shall have reported measurable increase in activity tolerance after 3 days of nursing interventions.

-Identify activity needs - To prevent or desired overexertion -To reduce

- Low paleness hematoc rit count ( .17) - Pale palpebra l conjunct iva - palen ess Patient may manifest the following: - Dizzin ess - Vertig o - Confu sion - Altere d mental

the glomerular tissues are inflammed. With this condition, the patient can have decrease level of hgb and hct. And since hgb is responsible for oxygenation of tissue, there will be decrease oxygen being delivered to the tissues of the body. As a compensatory mechanism, the body will increase demand of oxygen by increasing the respiratory rate of the patient

nursing intervention s, the patient will be able to report measurable increase in activity tolerance.

-Adjust activities -Plan care with rest periods between activities -Provide positive atmosphere, while acknowledgin g difficulty of the situation for the client -Promote comfort measures for relief from pain

fatigue

- Helps to minimize frustration re-channel energy

- To enhance ability to participate in activities - To sustain motivation

-To prevent injuries

status - Poor muscle tone

which results to fatigue. Because of this, there will be faster consumption of ATP leading to weaker contractions thus causing muscle weakness. And if the patient has muscle weakness, there will be activity intolerance.

-Give patient information that provides evidence of daily progress - To enhance sense of well-Assist being patient to learn and demonstrate appropriate safety measures -Encourage client to maintain positive attitude

Fatigue related to physiological factor:anemia ASSESSMENT S= O = the patient manifested the following: - body weakness - restles sness - physic al inactivity - Low hgb count (56) - Low hematocri NURSING DIAGNOSI S Fatigue r/t physiologi cal factor:an emia 2 to disease condition SCIENTIFIC EXPLANATION AGN is an inflammation of glomerular capillaries. Because of the inflammation , the function of the kidney for erythropoiesi s is affected which results in decrease RBC production leading to anemia. The body now will have OBJECTIVES Short Term: After 4 hours of nursing intervention s, the patient will be able to identify basis of fatigue and individual areas of control Long Term: After 1 week of nursing intervention INTERVENTIO N Establish rapport Monitor and record VS Identify presence of physical and/or psychological disease states RATIONALE - To gain patients trust and cooperation - To obtain baseline data - To assess causative or contributing factor EXPECTED OUTCOME

Short term: The patient shall have identified basis of fatigue and individual areas of control after 4 hours of nursing interventions. Long Term: The patient shall have performed ADLs at level of ability After 1 week of nursing interventions.

Determine ability to - To assess degree participate in of fatigue activities/lev el of mobility

t count ( .17) - Pale palpebral conjuncti va - palene ss Patient may Manifest: - dizziness -confusion - poor muscle tone - vertigo -altered mental status

decrease hgb and hct level. And since hgb is responsible for oxygenation of tissue, there will be less oxygen supply to tissues of the body. The body then will compensate by increasing the respiratory rate of the patient which may lead to fatigue.

s, the patient will be able to perform ADLs at level of ability.

Note daily energy patterns

- Helpful in determining pattern or timing of activity

Establish - Enhances realistic goals commitment to with patient promoting optimal outcomes Plan care to - To provide rest allow periods individually adequate rest periods Schedule activities for periods when patient has the most energy Provide environment To maximize participation

- Temperature and level of humidity are known to affect

conducive to relief of fatigue

exhaustion -To help patient to cope with fatigue

Assist with self care needs and ambulation as indicated -To provide comfort Promote quiet and relaxing environment -To promote venous return and Encourage gradually early increased ambulation patients ADL once tolerated - Impaired concentration can Avoid over limit ability to stimulation/ block competing under stimuli

stimulation Discuss routines Instruct in stress management skills of relaxation Instruct to avoid strenuous activity

- To promote sleep - To assist patient to cope with fatigue

-To conserve energy -to maintain weight and appropriate nutrition

Instruct to eat nutritious foods and foods rich in - To maintain iron strength and muscle tone and Refer to to enhance sense physical or of well-being therapy as

appropriate Fluid volume excess r/t disruption of regulatory mechanism AEB by facial edema ASSESSME NT S= O= patient manifeste d: NURSING DIAGNOSIS SCIENTIFIC EXPLANATION Acute glomerulonephritis is an inflammation of the glomeruli of the kidney. Children above 2y/o are at risk to have AGN caused mostly by an antrapment and collection of antigen-antibody complexes in the glomerular capillary membrane. The inflammation causes damage to the kidney, thus OBJECTIVES Short term: After 4 of nursing interventions the pt will be able to verbalize understandin g of individual fluid restrictions INTERVENTI ON - Establish rapport - Monitor VS and note level of consciousne ss -Monitor I & O RATIONAL E - To gain the trust of the client EXPECTED OUTCOME Short term: The pt shall have verbalized understanding of individual fluid restrictions after 4 hours of nursing interventions

Fluid volume excess r/t disruption of regulatory mechanism AEB - facia by facial edema 2 disease l edema condition c puffy eyelids - body malaise - cold and clammy skin - restl essness - Low

Long term: After 5 days

-Evaluate pt. mental

- To have a baseline data and to reveal Long term: alteration Pt. shall have demonstrated reduction of the recurrence of - To fluid excess after 5 days of reveal nursing interventions alteration in fluid status -To assess

hgb count (56) - Low hemato crit count( .17) - Albu min: +1 The patient may manifest: - Chan ges in mental status - Gen eralize edema - Dysp

altering the glomerular filtration rate that will eventually lead to excretion of albumin. With decreased albumin level will result to decrease colloidal oncotic pressure and will lead to shifting of fluid from intracellular to interstitial spaces causing the pt. to have edematous face, decrease hct, and hgb, and cold and clammy skin. because of this there is stasis of fluid, confirming the nursing diagnosis of excess fluid

of nursing status interventions the pt. will be able to demonstrate reduction of the recurrence of fluid excess _Provide quite environmen t -Encourage frequent change in position

for the presence of confusion , personali ty changes and to check for cerebral edema _to promote wellness -To reduce/p revent tissue pressure and risk of skin breaksdo wn

-Measure abdominal girth

nea - Chan ges in respirat ory pattern - Jugu lar vein distenti on

volume. - Restrict fluid/sodiu m intake as indicated -Administer diuretics as ordered

-To assess for increasin g fluid and edema -To reduce further edema -To promote fluid excretion

Self-care deficit related to weakness ASSESSMEN T S= NURSING DIAGNOSIS SCIENTIFIC EXPLANATION Because of impaired renal function, the kidneys can not produce erythropoietin, a substance necessary for hematopoiesis or RBC production. This event leads to anemia as evidenced by low level of hemoglobin which is primarily responsible for the transport of oxygen to the body. The patient is deprived of OBJECTIVES SHORT TERM: After 3 of nursing intervention, the pt will be able to identify individual areas of weakness and needs for self-care. INTERVENTI ON -Establish rapport RATIONALE EXPECTED OUTCOME

Self-care deficit O= related to The weakness Patient AEB unkempt manifested hair : untrimmed dirty toenails -body and weakness fingernails -pale palpebral conjunctiv a -pale nailbeds -low hemoglobi n count (56) -

-To gain the SHORT TERM: trust of the The pt shall have identified client individual areas of weakness and needs for -Determine self-care, After 3 of current Comprehens nursing intervention capabilities ive and barriers functional to assessment LONG TERM: participate included The pt shall have performed in self-care independent self-care activities within performanc the level of own ability, e of basic After 2 days of nursing ADLs, intervention social activities, LONG TERM: sensory After 2 days abilities and of nursing ability to intervention, -Identify ambulate the pt will reasons for

tachycardi a -unkempt hair untrimmed dirty toenails and fingernails - Low hgb count (56) - Low hemato crit count( . 17) The patient may manifest:

enough tissue oxygenation as hemoglobin drops to normal level. This may cause the patient to have pale palpebral conjunctiva and nail beds, tachycardia, dizziness, lethargy, drowsiness and muscular weakness. The patients energy reserve is depleted and experiences weakness. Because of such, the patient is not able to perform selfcare activities like maintaining appearance at a satisfactory level

perform self- difficulty in care self-care activities within the level of own ability. -Determine hygiene needs and provide assistance as needed with activities including care of hair, nails, skin and brushing of teeth

-Underlying cause affects choice of intervention or strategies and problem may be minimized -Meets the needs while supporting patient participatio n

-Determine individual strength and -Prepares skills of for patient increased

-dizziness drowsiness -lethargy

as evidenced by unkempt hair and as well as poor personal hygiene as evidenced by untrimmed and dirty toenails and fingernails.

independen ce which -Involve enhance patient in self-esteem formulation of plan of -Enhances care at level sense of of ability control and aids in cooperation and mainte-Promote nance of patient/SO independen participatio ce n in problem -Enhances identificatio commitmen n and t to the plan decision and making optimizes outcome -Encourage energy saving techniques -Conserves energy,

reduces fatigue and enhances -Shampoo or pts ability style hair as to perform needed and tasks provide or assist with -Aids in manicure maintaining appearance -Encourage or assist in routine mouth and teeth care -Reduces daily risk of gum disease/ tooth loss -Encourage and food and enhances fluid oral health choices reflecting -To meet individual nutritional likes demands especially

those rich in iron and vitamin C