CUES SUBJECTIVE: Tulo na ko ka.adlaw nga wala ka-libang.

Unya kung makalibang man ko, medyo gahi ang tae,as verbalized by the patient.

NSG DIAGNOSIS Constipation related to immobility and decreased fluid intake.

SCIENTIFIC RATIONALE Constipation is a common problem. It is often the result of restrictions of fluids and high-fiber foods, many of which are potassium and phosphorus-rich and decreased activity. Constipation provides a particular challenge, because the usual interventions for prevention and treatment are contraindicated in the client with renal failure. REFENCE: MedicalSurgical Nursing; A Psychophysiologcal Approach 4th Edition by Lukkmann and Sorensen page 1507

OUTCOMES OF CARE After 8 hours of implementation of nursing interventions, the patient:

1. Will be able to take out of bed and ambulate at least 10 steps per day as assisted by the significant others.

NURSING INTERVENTIONS INDEPENDENT: 1. Assessed the usual pattern of defecation, including time of day, amount and frequency of stool, history of bowel habits or laxative use.

SCIENTFIC RATIONALE 1. Normal" frequency of passing stool varies from twice daily to once every third or fourth day. Chronic use of laxatives causes the muscles and nerves of the colon to function inadequately in producing an urge to defecate. 2. Bowel sounds are generally decreased in constipation.

EVALUATION GOALS MET: 1. The client was able to ambulate 12 steps from his bed to the comfort room with assistance of his wife. 2. Fluid intake of 690 ml/ day. 3. Patient was able to pass out stool with mid-soft consistency.

OBJECTIVES: Decreased fluid intake= 240 cc/24hr Confined to bed. Low fiber diet (-) stool for 3 days Hard fecal mass In
HEMODIALY SIS therapy

2. Will be able to increase amount of water/fluid of at least 946-1,035ml. After 15 minutes of implementation of dependent nursing intervention: 1. The patient will be able to pass out softer stool within normal frequency.

2. Palpated for abdominal distension, percuss for dullness or auscultate bowel sounds.

3. Encouraged fiber intake of 5 to 15g/day as permitted by the physician.

4. Had the client deep breathe through the mouth.

3. Fiber passes through the intestine essentially unchanged. When it reaches the colon, it absorbs water and forms a gel, which adds bulk to the stool and makes defecation easier. 4. To encourage relaxation of the pelvic floor muscle and use the abdominal muscles to help evacuation. 5. May identify dehydration,

5. Monitored I & O.

6. Encouraged or assist with ambulation when able.

excessive loss of fluids or aid in identifying dietary deficiencies 6. Ambulation and/or abdominal exercises strengthen abdominal muscles that facilitate defecation.

DEPENDENT; 1. Administered Dulcolax 2 adult suppository as prescribed.

1. A laxative that stimulates bowel movements and used to treat constipation.

CUES SUBJECTIVE: Maglisod ko ug ginhawa, as verbalized by the patient.

NSG DIAGNOSIS Ineffective breathing pattern related to fluid accumulation secondary to renal dysfunction.

OBJECTIVES: RR = 32 CPM (Normal= 12-20 CPM) (+) Nasal flaring (+) rales Use of accessory muscles (+) rales (+) Orthopneic Dyspnea Maintained at semi fowlers position pH=7.21 UO= 21O cc/ 8hr Increased BUN = 44.3 mmol/L (Normal= 2.5 8.3 mmol/L) Increased Cratinine = 2,740 umol/l (Normal= 71-115 umol/L)

OUTCOMES OF CARE NURSING INTERVENTIONS NURSING INTERVENTIONS: Some of the respiratory After immediate implementation of INDEPENDENT: effects, such as nursing interventions: 1. Monitored RR, depth and pulmonary edema, can ease of respiration. 1. The patient be attributed to fluid will be able to overload. Pleuritis is a maintain respiratory frequent finding, rate within especially when normal range. pericarditis develops. A 2. The patient 2. Observed for the color of will be able to the tongue, oral mucosa characteristics condition report and skin. called UREMIC LUNG is cessation of a type of pneumonitis orthopneic dyspnea. that responds well to
fluid removal. Metabolic acidosis causes a

SCIENTIFIC RATIONALE

SCIENTFIC RATIONALE

EVALUATION Goals partially met: Respiratory rate of 23 CPM. Neither nasal flaring nor use of accessory muscle noted. Client reported ability to breathe normally in supine position. Decreased creatinine level but still above normal range. Creatinine: 849.83umol/L (Normal= 71-115 umol/L)

1. Respiratory distress and changes in vital signs occur because of physiological stress and pain or may indicate development of shock due to hypoxia or hemorrhage. 2. Cyanosis of the tongue and oral mucosa is central and generally represents a medical emergency. Peripheral cyanosis of nail beds or lips may or not be serious. 3. Positioning helps maximize lung expansion and decreases respiratory effort. 4. Creates resistance against outflowing air to prevent collapse/narrowing of the airways, thereby helping distribute air throughout the lungs and relieve/reduce shortness of breath. 5. Accurately measuring I & O is very important for the client fluid overload.

After 2 sessions of hemodialysis and compensatory increase implementation of nursing interventions, in respiratory rate as the the patient will lungs work to eliminate manifest:
excess hydrogen ions. REFERENCE: Medical-Surgical Nursing by Black and Hawks 7th Edition Volume 1 page 953

3. Placed patient in semi or high-fowlers position. 4. Supported client in using pursed-lip breathing and controlled breathing techniques

1. Gradual increase of urine output. 210 cc/8hr 2. BUN and creatinine levels within normal range.

BUN within the normal range: BUN: 5.15 mmol/L (Normal= 2.5 8.3 mmol/L) Gradual increase of urine output from 210 cc/8hr to 450 cc/ 8hr. Latest (10-15-11: 700 cc/8hr)

5. Monitored the intake and output; note trends reflecting decrease in

Chest X-ray: minimal pleural effusion

3. Lower extremities will be free from edema. 4. Normal lung sounds. 5. Normal lung field.

urine output fluid intake. 6. Monitored sounds for respiratory presence of orthopnea.

in relation to for crackles effort dyspnea lung and and and 6. To evaluate presence/character of breath sound/secretions.

(-) edema in the lower extremities No follow up chest radiologic exam.

DEPENDENT: 1. Administered MANNITOL 75ml IV every 8 hours to start post HD for 3 doses. Check BP before administration 2. Prepare and position the client for thoracentesis if indicated.

1. Used to increase urine production (diuretic). It is used to treat or prevent medical conditions that are caused by an increase in body fluids/water. 2. To remove fluid from the space between the lining of the outside of the lungs (pleura) and the wall of the chest. To provide relief of causative agents.

CUES SUBJECTIVE: Namuya ug nanghubag ang iyang samad,as verbalized by the patient.

NSG DIAGNOSIS SCIENTIFIC RATIONALE OUTCOMES OF CARE Infection related to Impairment of the After 30 min. of immunosuppression implementation of immune system makes nursing intervention: the client more susceptible to infection. Patients body temp must fall within the Several factors are normal range of involved, including 36.5-37.5 C.
depression of humeral anti-body formation,

NURSING INTERVENTIONS SCIENTFIC RATIONALE NURSING INTERVENTIONS: INDEPENDENT: 1. Measured and recorded 1. Reflective of inflammatory clients temperature every process/infection requiring 4-6 hours. evaluation in treatment

EVALUATION Goals partially met as evidenced by: Temperature within normal. Temp:36.2 C

OBJECTIVES: T = 39C (Normal:36.537.5) PR = 130 (Normal:60100) RR = 32 (Normal:15-30) Increased WBC = 19.3 (Normal:5.0 10. 0 ) Increased Neutrophil = 0.92 (Normal:0.45- 0.65) Swelling at the right Intrajugular vein

suppression, of delayed hypersensitivity,

Patients vital signs within normal range.

and S.O will demonstrate appropriate care of decreased chemotactic infection-prone site to be evaluated action of leukocytes. by end of shift. Immunosuppression is an important part of the

2. Used the same site and method for temperature measurement for a given client.

Long Term: medical management of Client will remain free from symptoms renal diseases such as of infection as glumerulonephritis. measured by WBC within normal limits REFERENCE: to be evaluated Medical Surgical before discharge. Nursing by Black and Hawks 7th Edition Volume 1 page 953

2. Instituted measures to decrease temperature such as cooling the environment, removing excess clothing and perform TSB not leaving the clients skin wet. 4. Observed proper control.

Heart rate decreased but still above the 2. A difference in the site (oral, normal range: rectal, or axillary) of PR = 112 BPM temperature measurement (60-100 Bpm) results in a significant difference in temp reading. Decrease of white blood cell count but 3. To promote heat loss by still above normal evaporation and conduction. range. WBC = 18 (Normal:5.0- 10. 0 ) Decrease in swelling at the right intrajugular vein Decrease BUN = 5.15 mmol (Normal= 2.5 8.3 mmol/L) Dec. Creatinine = 849.83 umol/L (Normal = 71-115 umol/l)

infection 4. To prevent/minimize further infection.

DEPENDENT: 1. Administered Paracetamol 1. Elimination of fever will 300 mg IVTT. interfere with its enhancement of the immune response. 2. Administered Cefuroxime 2. To treat certain infections 1.5 mg IV LD then 750 mg caused by bacteria.

 Inc. BUN = 44.3 mmol/l (Normal= 2.5 8.3 mmol/L) Inc. Creatinine = 2,740 umol/L (Normal = 71-115 umol/l)

IV every 8 hours ANST (-). 3. Notify the physician of 3. A change in mental status may temperature according to indicate the onset of septic shock. institutional standards or when written orders or when temperature reaches 38C. Also notify the physician of the presence of a change in mental status.

S.O demonstrate appropriate care like handwashing before and after handling the site.