Assessment Nursing Scientific Planning Nursing Rationale Evaluation

Diagnosis Rationale Intervention

S: Ineffective Septick shock Long outcome: Assess the To get tha baseline Long
nahihirapan po Airway Client will respiratory rate, data outcome:
ako huminga,hindi po Clearance maintain an rhythm, and depth, Client
ako makahinga ng related Systemic effective breathin and note for maintained
maayos as verbalized Bronchospas antigen- g pattern, as changes an
by the patient m as antibody evidenced by effective bre
evidence by immune relaxed breathing athing
O: nasal flaring, response to a at normal rate pattern, as
Nasal flaring increase RR. foreign and depth and Assess the Life-threatening evidenced
Increaserespiratory restlessness substance absence of clients anxiety level situations such as by relaxed
rate adventitious . shock can produce breathing at
Restlessness breath sounds. elevated levels normal rate
Peripheralcyanosis Smooth muscle of anxiety and depth
(nailbeds) contraction Short outcome: and absence
Cold clammyskin After 5-10 Monitor oxygen Pulse oximetry is of
(hands) minutes, the saturation and used to monitor adventitious
Massive patient will be arterial blood oxygen saturation. breath
vasodilation and able to breath in gasses. It should be kept at sounds.
increased with ease least 90% or
capillary trigger higher. Short
outcome:
Instruct the client to Focus breathing After 5-10
Progress to breathe slowly and may help calm the minutes, the
rapidly to deeply. client, and the patient able
respiratory increase tidal to breath in
distress volume facilitates with ease
improved gas
exchange.
Difficulty of Position the client
breathing upright. This position
provides
oxygenation by
Ineffective promoting
airway maximum chest
clearance expansion

Administer oxygen Oxygen increase

as prescribed. arterial saturation.

Administer red May be required to

blood cells (RBCs), improve available
as indicated. oxygen to treat
sepsis-induced
hypo perfusion, or
when the
hematocrit falls
below 30%.
Assessment Nursing Scientific Planning Nursing Rationale Evaluation
Diagnosis Rationale Intervention

S: Excess fluid Renal disorder Patient display Accurately record Accurate Patient
sobrang dami nap o volume impairs appropriate intake and output monitoring of I&O displayed
ng ihi niya pero and related to glomecular urinary output (I&O) noting to is necessary for appropriate
onti lang naman po ng compromised filtation that with specific include hidden determining renal urinary
tubig na pinapainom regulatory resulted to fluid gravity/laboratory fluids such as IV function and fluid output with
sa kaniya as mechanism overload with studies near antibiotic additives, replacement needs specific
verbalized by the possibly fluid volume normal; stable liquid medications, and reducing risk of gravity/labor
patient evidenced by excess weight, vital signs frozen treats, ice fluid overload atory studies
intake greater within patients chips. near normal;
Objective: than output, Hydrostatic normal range; stable
Prescence of generalized pressure is the and absence of Monitor urine Measures the weight, vital
urinary edema,weigh higher than the edema. specific gravity. kidneys ability to signs within
catheter t gain, usual pushing concentrate urine patients
Input of 200 changes in excess fulids normal
Output of 450 metal into the Weigh daily at Daily body weight range; and
ml status,restles interstitial space same time of day, is best monitor of absence of
sness on same scale, fluid status edema.
with same
Since fluid are equipment and
not reabsorbed clothing.
at the venous
end fluid Assess skin, face, Edema occurs
become over dependent areas primarily in
load thats there for edema. dependent tissues
is excess fluid Evaluate degree of of the body,
volume edema (on scale of (hands, feet,
+1+4) lumbosacral area).

Tachycardia and
Monitor heart rate hypertension can
(HR), BP, and occur because of
JVD/CVP. failure of the
 kidneys to excrete
urine

The oliguric patient

Administer and/or with adequate
restrict fluids as circulating volume
indicated. or fluid overload
who is
unresponsive to
fluid restriction
and diuretics requir
es dialysis.
Assessment Nursing Scientific Planning Nursing Rationale Evaluation
Diagnosis Rationale Intervention

S: Hyperthermia Septic shock Long term Established Promotes Long term

2 days ago related to outcome: rapport cooperation of the outcome:
nagkaroon siya ng inflammatory After 1 hour of significant other After 1 hour
lagnat as verbalized process as Pooling of nursing of nursing
by the significant manifested Bactrian in the intervention the Monitor Helps the nurse to intervention
other by increased blood stream patients temperature identify the the patients
body temperature will development of the temperature
O: temperature decrease from patients decreased
Body temp: Inflammatory 38.3 to 37.4 temperature from 38.3 to
38.3 process initiated 37.4
Warm and Monitor Hyperventilation
flushed skin Short term other vital may initially be
Facial grimace Vascular outcome: signs such present Short term
Chills noted changes After 15 minutes as outcome:
of nursing respiratory After 15
intervention client rate and minutes of
Cellular relief of signs of pulse rate nursing
changes like discomfort and intervention
leukocytes vital sign goes Monitor Ventilatory effort client was
increase back in normal ventilatory may be impaired relief of
range effort due to signs of
hypermetabolic discomfort
Local effects state and possible and vital
(warmth,swellin seizures sign goes
g,impaired back in
functioning) Monitor fluid Fluid and normal
loss like electrolyte may be range
vomiting, loss due to
Systemic effect diarrhea and dehydration
(Fever) urine output

Promote Promotes heat loss

surface by radiation and
 cooling like conduction
undressing
or wearing
light weight
clothing

Perform tipid Promotes heat loss

sponge bath by evaporating and
conduction

Increase To replace fluid

fluid intake and to support
circulating

Give anti- To reduce fever

pyretic as
ordered by
the
physician