Case NCP

ASSESSMENT NURSING DIAGNOSIS

PLANNING INTERVENTION NURSING COMPETENCY

NURSING THEORIES

EVALUATION

Subjective: “Nahapo kag maluya siya sa gihapon”, as verbalized by the mother.

Objective:Hemoglobin= 56 gms/LRBC count=2.00x10^12/LHematocrit=0.17 Vol(fr) ESR=147 mm/hrChest PALImpression: Pulmonary Congestion Hyperaerated Lungs CardiomegalyRR= 33bpmNasal flaring notedSuprasternal retractions notedPallor on palms and skinPale conjunctivaeChild is restless.

Impaired gas exchange r/t

altered oxygen-carrying

capacity of blood

The patient will demonstrate

adequate oxygenation with a respiration of 33 bpm to 12-25 bpm

and absence of nasal flaring and

suprasternal retractions after one (1) hour of

nursing intervention.

Independent:1.)Noted respiratory rate, depth, use of accessory muscles and areas of pallor.To evaluate degree of compromise.

2.) Auscultated lung fields, noting areas of decreased or absent airflow and adventitious breath sounds (crackles and wheezes).Decreased airflow occurs in areas consolidated with fluid.

3.) Elevated head of bed and changed positions every 2 hours or PRN. Promotes optimal chest expansion.

4.)Monitored I&O, limiting intake to not more than 800

Safe & Quality Nursing Care




Faye Glenn Abdellah’s

Typology of 21 Nursing Problems

“To facilitate the maintenance of a supply of oxygen to all body cells.” Cells need oxygen in order to play their vital function as basic unit of life. Any depletion of oxygen may lead to the malfunctioning of cells.

mL/day.To prevent hyperviscosity of blood.

5.)Encourage deep-breathing exercises.Promotes optimal chest expansion.

6.)Encouraged adequate rest and limit activities to within patient’s tolerance.Helps limit oxygen needs and consumption.

7.)Encouraged mother and folks to maintain cleanliness and orderliness of the room to keep environment allergen and pollutant free. To reduce irritant effect of dust and chemicals on airways.

8.)Emphasized the importance of maintaining optimal nutrition by consuming the meals

Health Education

Health Education

Management of Resources & Environment

Communication

Virginia Henderson’s

14 Basic NeedsHenderson identified patient’s need for :a.)elimination of body wastes;b.)move and maintain comfortc.)sleep and rest

Florence Nightingale’s

Environmental Theory

She states that nature or environment allows reparative process to occur or alter to prevent or cure diseases.



prepared by the hospital’s dietary section.Improves stamina and reduced the work of breathing.

Dependent:

1.)Provided supplemental O2

at 1 LPM via nasal cannula.Maximize O2 transport to tissues.

2.)Administered 1 pack RBCs, monitoring closely for transfusion reactions.Increases number of oxygen-carrying cells, dilutes percentage of Hbs, and improves circulation.

Legal Responsibility


Nightingale addressed the need to maintain optimal nutrition by eating appropriately and adequately.

3C’s of Lydia HallCare, Core ,Cure

The Cure Circle is based in the pathological and therapeutic sciences and is shared with other members of the healthcare team.



NURSING THEORIES

EVALUATION

Subjective:“Daw nabudlayan siya pirmi magginhawa”, as verbalized

Altered Tissue Perfusion r/t decreased

After two (2) hours of nursing

intervention,

Independent:1.)Assessed hydration status.



by the mother.

Objective:Hemoglobin= 56 gms/LRBC count=2.00x10^12/LHematocrit=0.17 Vol(fr) ESR=147 mm/hrRR= 33bpmBP=90/50 mmHgChest PALImpression: Pulmonary Congestion Hyperaerated Lungs CardiomegalyCapillary refill=4 secondsDysrhythmias notedNasal flaring notedSuprasternal retractions notedPallor on palms and skinPale conjunctivae() facial edema

hemoglobin concentrations

in blood

patient will achieve normal respirations and blood pressure from 33 bpm to 12-25 bpm and

from 90/50 mmHg to 105+13(sys)

mmHg respectively.

Dehydration reduces glomerular filtration rate (GFR).

2.)Monitored fluid intake, urine output and weighed daily.To provide non-invasive assessment of cardiovascular and renal function.

3.)Monitored vital signs, especially noting blood pressure changes, including hypertension or hypotension.Any of which places patient at high risk for kidney damage. 4.)Provided periods of undisturbed sleep and calming environment.To reduce myocardial workload.

5.)Provided for fluid and diet restriction (not more than





Typology of 21 Nursing Problems

Abdellah identified the patient’s need to:

a.)facilitate the maintenance of fluid and electrolyte balance;

b.)recognize the physiological responses of the body to disease conditions---pathological, physiological, compensatory;

c.)promote optimal activity, exercise, rest and sleep.

Dorothea Orem’s Self-Care Deficit

800 mL/day and ) while providing adequate calories and hydration.To meet the body’s need without overtaxing kidney function.

6.)Encouraged mother and folks for regular check-up and laboratory follow-up upon discharged.To provide monitoring and earlier intervention of underlying condition, and to evaluate effectiveness of therapeutic interventions.

Dependent:1.)Provided supplemental O2

at 1 LPM via nasal cannula.To improve tissue perfusion/organ function.

Health Education

Quality Improvement


TheoryOrem identifies self-care requisites as the maintenance of a sufficient intake of water or other fluids.

Imogene King’s Goal Attainment

TheoryKing stated that the nurse brings specialized knowledge and skills and can communicate information that is helpful in setting goals.


The Cure Circle is based in the pathological and therapeutic sciences and is shared with

other members of the healthcare team.



NURSING THEORIES

EVALUATION

Subjective: “Daw gapanghabok iya itsura”, as verbalized by the mother.

Objective:RR= 33bpmBP=90/50 mmHgHemoglobin= 56 gms/L

Excess fluid volume r/t excess

fluid retention secondary to Acute Post-

streptococcal Glomerulonephritis

and its medical therapy

After four (4) hours of nursing

intervention, patient will have his RR and BP within normal

limits.

Independent:1.)Monitored BP and RR every 2 hours.Hypertension and elevated RR may reflect developing/increasing pulmonary congestion.


Jean Watson’s Theory of

Transpersonal Nursing

She identified in her

Hematocrit=0.17 Vol(fr)Chest PALImpression: Pulmonary Congestion CardiomegalyCrackles and wheezes on auscultation (+) Grade 3 organic systolic murmur

2.)Closely monitored fluid intake from all sources including p.o.(by mouth) and I.V., limiting fluid intake to not more than 800 ML/day and Na(Sodium) intake of not more than /day.To assess precipitating factors.

3.)Monitored urine output, noting amount and color.Urine output may be scanty and concentrated because of reduced renal perfusion.

4.)Weighed and recorded patient daily every morning.Provides comparative baseline and evaluates the



Record Management

carative factors the need of assisting gratification of basic human needs while preserving human dignity and wholeness.

Dorothea Orem’s Self-Care Deficit

TheoryOrem identifies self-care requisites as

the provision of care associated with

elimination processes and excrements.



effectiveness o diuretic therapy.

5.)Placed patient in semi-fowlers position during rest time.To facilitate movement of diaphragm, thus improving respiratory effort.

6.)Promoted early ambulation and the maintenance of a quiet environment, limiting external stimuli.To promote mobilization/elimination of excess fluid.




She also discussed “Petty

Management”, which includes the documentation of

plan of care, monitoring of

intervention and evaluation of

outcomes to ensure continuity.


Typology of 21 Nursing ProblemsShe acknowledged the importance of promoting optimal activity; exercise,

rest and sleep and the creation and maintenance of a

therapeutic environment.

Dependent:1.)Maintained fluid and sodium restrictions as indicated.Reduce total body water/ prevents fluids reaccumulation.

2.)Administered Furosemide 7 mg IV, Q12H. A potent loop diuretic inhibiting sodium and chloride reabsorption, leading to a sodium-rich dieresis.



3C’s of Lydia HallThe Cure Circle is based in the pathological and therapeutic sciences and is shared with other members of the healthcare team.


The Cure Circle is based in the pathological and therapeutic sciences and is shared with other members of the healthcare team.



NURSING THEORIES

EVALUATION

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Case NCP