Cues/clues S> masakit ang likod ko as verbalized

Nursing Diagnosis Alteration in

Plan

Nursing Interventions

Rationale For baseline data For baseline data To promote comfort and relaxation To divert focus of attention to pain To prevent pain stimulation To promote comfort and relaxation For pharmacologic intervention

Evaluation Medyo nawala na ung sakit ng likod koas verbalized Pain scale= 6/10 BP=90/60

At the end of nursing Assessed severity of pain using pain scale Monitor VS esp. BP Provided comfort measures such as positioning Provided diversional activities such as listening to music or talking to S.O. Instructed S.O. not to leave the patient alone Provided therapeutic touch Demonstrated and encouraged to do deep breathing exercise Encouraged back tapping Avoid abrupt movements Provided adequate rest and sleep periods Administered analgesics as ordered

comfort; flank pain intervention the secondary to disease condition patient will be able to demonstrate ways and technique on how to reduce pain to a tolerable level

O> with facial grimace Irritable at times Slightly weak in appearance With guarding behavior Pain scale=8/10 BP=110/80

Cues/clues

Nursing Diagnosis

Nursing Plan

Nursing Interventions assess contributing factors assess general appearance instruct to move gradually and have a gradual increase in activities encourage to avoid strenuous activities assist in moderate high back rest encourage to limit intake of salty and fatty foods instruct the SO not to leave the patient alone PRN meds given

Rationale serves as baseline data serves as baseline data serves as baseline data to prevent dizziness to prevent dizziness to promote relaxation and comfort to prevent water retention to prevent injury through proper supervision for pharmacological purposes

Evaluation Seen pt in semi-fowlers position Seen SO always on bedside Seen pt moving gradually BP=130/90

O>BP = 150/90mmHg >PR = 89bpm >episodes of dizziness >slightly pale nail beds; capillary refill time of 2-3 seconds

Decrease cardiac output related to increase peripheral

At the end of nursing

interventions, patient monitor v/s esp. blood pressure

vasoconstriction as with the help of SO evidenced by elevated blood pressure will be able to demonstrate ways and techniques on how to normalize cardiac output and maintain blood pressure within normal range

Cues/ Clues

Nursing Diagnosis

Plan/Goal

Nursing Interventions Assess capability to do activities Instruct SO to clean and cut long fingernails Instruct SO to do sponge bath Encourage the patient to take a bath Encourage to do oral hygiene Encourage SO to be involve in giving patient proper hygiene Instruct SO to provide non-constricting clothes Encourage patient to splash a little baby cologne after bath

Rationale To identify the patients status To educate the patient about the importance of hygiene For proper personal hygiene For proper personal hygiene For proper personal hygiene For proper personal hygiene For the SO will be able to apply the procedures at home To make the patient feel comfortable For the patient to feel fresh

Evaluation Seen S.O. wiping patients extremities Seen S.O. assisting patient in changing of clothes and doing some activities

O Weak in appearance With assistance With dry slightly skin With easy fatigability With long nails

Self-care deficit related to decrease strength and endurance

At the end of the

nursing interventions Discuss the importance of hygiene the patient with the help of the S.O, will be able to identify ways on how to enhance proper hygiene

in doin activities secondary to disease condition

Cues/ Clues

Nursing Diagnosis

Plan/Goal

Nursing Interventions Assess general condition Assess contributing factors Assess the characteristic of edema Monitor VS esp. BP Instructed to limit fluid intake to less than 1L a day Put pillows under both legs Instructed to turn side to side at least every 2 hours Advised to eat foods rich in albumin such as egg white Regulate IVF properly Emphasized the importance of furosemide treatment Encouraged to have adequate rest and sleep Emphasized the importance of strict adherence to treatment regimen

Rationale For baseline data For baseline data For baseline data For baseline data To avoid fluid accumulation in the body To increase venous return To help in fluid shift To help in lessen the edema For rehydration To help in the disease condition To regain body strength For faster prognosis

Evaluation Seen with pillows under the legs Seen drinking ample amount of water

O With edema on the feet +1

Fluid volume excess related to compromised regulatory mechanism secondary to disease condition

At the end of the nursing intervention the patient will be able to identify ways on how to lessen fluid volume excess

Cues/ Clues S> Wala kaming pera, naghahanap ng pa kami ng pagkukunan para makabili ng pangsalin ng dugo

Nursing Diagnosis Noncompliance to treatment regimen r/t lack of involvement financial problems

Plan/Goal

Nursing Interventions Identified strategies most effective for S.O. Encouraged S.O. on verbalization of feelings Helped S.O. in understanding the need for the following treatment and consequences of non-compliance Emphasized the importance of adherence to treatment regimen Provided emotional support to S.O.

Rationale For S.O. to easily complete with the treatment To asses emotional response that interfere with compliance For the S.O. to realize the importance of the treatment For the S.O. to understand the need for the following the prescribed treatment To help S.O. cope up with the problem

Evaluation Tranfused 1 U of FWB

At the end of nursing intervention the S.O. with the patient will be able to realize the importance of compliance to

O> still for blood transfusion >without any contraptions

treatment regimen

Cues/ Clues

Nursing Diagnosis

Plan/Goal

Nursing Interventions Assessed causative factors such as bleeding Monitored V/S esp. PR Assessed capillary refill time Monitored and reviewed findings Encouraged to eat Iron-rich foods like green leafy vegetables like malunggay Encouraged to increase intake of Vit. C Regulated IVF properly Encouraged to turn from side to side Instructed to increase fluid intake Encouraged to do O2 conservation techniques such as sitting and sleeping Watched out for any sign of bleeding Provided safety measures Advised to avoid strenuous activities Provided bed exercises with proper instruction to S.O.

Rationale To see cause of decreased in Hgb in the blood To identify any alteration To assess for tissue perfusion To identify progression of dse. To facilitate adequate tissue perfusion For better absorption and increase resistance of body to infection To maintain hydration To improve circulation To support circulating volume and tissue perfusion To conserve O2 of body

Evaluation Hgb=11.3 Hct=35% With pinkish nailbeds With pinkish conjunctiva FWB transfused

O Hgb=9gm/dl Hct= 29.6 Poor skin turgor Pale conjusctivae With Pale and slightly dry lips Pale nailbeds, 2-3upon blanching Slightly pale in appearance For BT

Altered tissue perfusion related to decreased O2 carrying capacity of the blood as revealed in the laboratory results

At the end of nursing intervention the patient will demonstrate ways and technique on how to improve arterial circulation

 To prevent further damage To prevent further injury To promote wellness, provide optimum health and improve blood count levels Too improve circulation

Cues/ Clues

Nursing Diagnosis

Plan/Goal

Nursing Interventions Monitored Intake and output and characteristic of urine Encourage oral fluid intake Investigate reports of bladder fullness or palpate suprapubic distention Document any stone expelled and send laboratory for analysis

Rationale For baseline data To lessen concentration of the urine For hydration To eliminate bladder distention

Evaluation With slightly colored urine

O>with yellow to brownish colored urine No crystals or blood observed Goes to comfort room twice per shift

Impaired urinary elimination related to decreased renal perfusion secondary to disease condition; nephrolithiasis

At the end of the nursing intervention the patient will vid in normal amounts and usual pattern

Cues/ Clues S Ano bang nagyayari kapag nagkakabato as verbalized.

Nursing Diagnosis Knowledge deficit related to lack of information regarding current

Plan/Goal

Nursing Interventions Reviewed disease process and potential complications Stressed the importance of increased fluid intake (3-4 L/day) Encouraged to notice dry mouth and excessive diaphoresis and to increase fluid intake whether or not feeling thirsty Encourage to eat low salt low fat foods Discussed medication regimen

Rationale For baseline data To impart knowledge To help avoid foods that may complicate condition To avoid dehydration

Evaluation Seen drinking plenty of water. Seen eating citrus foods

At the end of the shift the patient will be able to verbalize understanding of his disease process and potential complications

O>asking questions about his health problem >Asks regarding the food he can eat >Unfamiliar with the things that contributes to his health problem like eating salty foods

health condition

Cues/ Clues S> hindi ako madumias verbalized.

Nursing Diagnosis Constipation related to insufficient

Plan/Goal

Nursing Interventions Monitored input and output Auscultated for bowel sounds Instructed to increase oral fluid intake at least 6-8 glasses per day Instructed to eat high in fiber foods such as oranges. Encourage to increase mobility or exercise such as walking

Rationale For baseline data to help stimulate bowel movement and for hydration to help stimulate bowel movement

Evaluation still with negative bowel movement

At the end of the nursing intervention the patient will demonstrate behaviors to relieve constipation

O>hypoactive bowel sounds upon auscultation, 3bpm >with negative bowel movement for 1 week

physical activity