Nursing Management A. Nursing Care Plan

NURSING MANAGEMENT a. Nursing Care Plan Ineffective Tissue Perfusion related to decrease in hemoglobin count CUES NURSING SCIENTIFIC OBJECTIVE DIAGNOSIS EXPLANATION S=Ø

Ineffective tissue perfusion O = the patient related to manifested: decrease in hemoglobin - Low hgb count (56) count (56) - Low hematocrit count ( .17) - Paleness - Pale Palpebral conjunctiva - Body weakness - Restlessn ess - Cold and clammy skin The patient may manifest - Bronchos pasm - Dysrhyth mias - Capillary

Acute glomerulonephritis is an inflammation of the glomerular capillaries. Because of 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 due to decrease production of RBC

Short term: After 4 hrs of nursing interventions the patient will be able to verbalize understanding of condition and therapy regimen Long Term: After 5 days of nursing interventions the patient will be able to demonstrate increased perfusion as individually appropriate

NURSING INTERVENTION - Establish rapport - Monitor record VS

RATIONALE

DESIRED OUTCOME

-To gain trust and cooperation and -To have baseline data

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Short term: The patient shall have verbalized understanding of condition and therapy regimen after 4 hours of nursing interventions

-Assess pt. gen. -To have condition baseline data and note any abnormal Long Term: findings The patient shall have -Encourage -To conserve demonstrated quiet, restful energy/lower increased atmosphere tissue oxygen perfusion as demands individually appropriate after -Encourage early -To enhance 5 days of nursing ambulation once venous return interventions tolerated -Discourage -To improve and sitting/standing facilitates good for long periods, circulation wearing constrictive clothing, crossing legs

refill longer than 3 secs - Use of accessory muscle in breathing - Nasal flaring

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

- Check for calf -May indicate tenderness thrombus formation - Elevate head -To increase of bed gravitational especially at blood flow night -Instruct to -To conserve avoid strenuous energy activity - Restrict sodium, fluid and fat intake as indicated

-To decrease excess fluid volume

- Instruct patient’s SO about food rich in iron

-To increase hgb count

-Regulate IVF As ordered

-To maintain hydration

-Promote adequate bed rest

-To promote wellness

- Attend needs

-To promote health

-Administer meds as ordered

-To promote recovery

Activity Intolerance related to muscle weakness ASSESSMENT

S=Ø

NURSING DIAGNOSIS

Activity Intolerance O = Patient related to manifested the muscle following: weakness aeb physical - body inactivity, Low hgb weakness - restless count (56) Low ness - physica hematocrit ( . l inactivity count 17) - Low hgb count Pale palpebral (56) conjunctiva - Low hematocrit paleness count ( . 17) - Pale palpebral conjunctiva - palenes s Patient may manifest the following: -

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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 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

OBJECTIVES

INTERVENTION

RATIONALE

EXPECTED OUTCOME

Short Term: After 4 hours of nursing interventions, the patient will be able to verbalize understanding of the causative factors and necessary interventions.

-Establish rapport

- To obtain patient’s cooperation

-Monitor and record VS

- To obtain baseline data

-Note patient’s report of weakness, fatigue and pain

-To identify contributing factors

Short Term: The patient shall have verbalized understanding of the causative factors and necessary interventions after 4 hours of nursing interventions.

-Identify activity needs or desired

-To know the appropriate activity level

-Adjust activities

- To prevent overexertion

-Plan care with rest periods between activities

-To reduce fatigue

-Provide positive atmosphere, while acknowledging difficulty of the situation for the

- Helps to minimize frustration rechannel energy

Long Term: After 3 days of nursing interventions, the patient will be able to report measurable increase in activity tolerance.

Long Term: The patient shall have reported measurable increase in activity tolerance after 3 days of nursing interventions.

ss - Vertigo - Confusi on - Altered mental status - Poor muscle tone

mechanism, the body will increase demand of oxygen by increasing the respiratory rate of the patient 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.

client -Promote comfort - To enhance measures for ability to relief from pain participate in activities -Give patient information that provides evidence of daily progress

- To sustain motivation

-Assist patient to learn and demonstrate appropriate safety measures

-To prevent injuries

-Encourage client to maintain positive attitude

- To enhance sense of wellbeing

Fatigue related to physiological factor:anemia ASSESSMENT S=Ø O = the patient manifested the following: - body weakness - restlessn ess - physical inactivity - Low hgb count (56) - Low hematocrit count ( .17) - Pale palpebral conjunctiva - paleness Patient may Manifest: - dizziness -confusion - poor muscle tone - vertigo

NURSING DIAGNOSIS

SCIENTIFIC EXPLANATION

Fatigue r/t physiological factor:anem ia 2° to disease condition

AGN is an inflammation of glomerular capillaries. Because of the inflammation, the function of the kidney for erythropoiesis is affected which results in decrease RBC production leading to anemia. The body now will have 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

OBJECTIVES

INTERVENTION

Short Term: After 4 hours of nursing interventions, the patient will be able to identify basis of fatigue and individual areas of control

Establish rapport

- To gain patient’s trust and cooperation

Monitor and record VS

- To obtain baseline data

Identify presence of physical and/or psychological disease states

- To assess causative or contributing factor

Long Term: After 1 week of nursing interventions, the patient will be able to perform ADLs at level of ability.

RATIONALE

Determine ability - To assess degree of to participate in fatigue activities/level of mobility Note daily energy patterns

- Helpful in determining pattern or timing of activity

Establish realistic goals with patient

- Enhances commitment to promoting optimal outcomes

Plan care to allow individually adequate rest periods

- To provide rest periods

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.

-altered mental status

of the patient which may lead to fatigue.

Schedule activities for periods when patient has the most energy

To maximize participation

Provide environment conducive to relief of fatigue

- Temperature and level of humidity are known to affect exhaustion

Assist with self care needs and ambulation as indicated

-To help patient to cope with fatigue

Promote quiet and relaxing environment

-To provide comfort

Encourage early ambulation once tolerated

-To promote venous return and gradually increased patients ADL

Avoid over stimulation/ under stimulation

- Impaired concentration can limit ability to block competing stimuli

Discuss routines

- To promote sleep

Instruct in stress

- To assist patient to

management skills of relaxation

cope with fatigue

Instruct to avoid strenuous activity

-To conserve energy

Instruct to eat nutritious foods and foods rich in iron

-to maintain weight and appropriate nutrition

Refer to physical or therapy as appropriate

- To maintain strength and muscle tone and to enhance sense of well-being

Fluid volume excess r/t disruption of regulatory mechanism AEB by facial edema

ASSESSMENT S= Ø O= patient manifested: - facial edema c puffy eyelids - body malaise - cold and clammy skin - restle ssness - Low hgb count (56) - Low hematocr it count( . 17) - Album in: +1 The patient may manifest:

NURSING DIAGNOSIS

SCIENTIFIC EXPLANATION

OBJECTIVES

Fluid volume excess r/t disruption of regulatory mechanism AEB by facial edema 2° disease condition

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 antigenantibody complexes in the glomerular capillary membrane. The inflammation causes damage to the kidney, thus 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,

Short term: After 4º of nursing interventions the pt will be able to verbalize understanding of individual fluid restrictions

Long term: After 5 days of nursing interventions the pt. will be able to demonstrate reduction of the recurrence of fluid excess

INTERVENTION

RATIONALE

EXPECTED OUTCOME

- Establish rapport

- To gain the trust of the client

- Monitor VS and note level of consciousness

- To have a baseline data and to reveal alteration

Short term: The pt shall have verbalized understanding of individual fluid restrictions after 4 hours of nursing interventions

-Monitor I & O

- To reveal alteration in fluid status

-Evaluate pt. mental status

-To assess for the presence of confusion, personality changes and to check for cerebral edema

_Provide quite environment

_to promote wellness

-Encourage frequent change in position

-To reduce/prev ent tissue pressure and risk of

Long term: Pt. shall have demonstrated reduction of the recurrence of fluid excess after 5 days of nursing interventions

- Chang es in mental status - Gener alize edema - Dyspn ea - Chang es in respirator y pattern - Jugul ar vein distention

confirming the diagnosis of fluid volume.

nursing excess

skin breaksdown -Measure abdominal girth

-To assess for increasing fluid and edema

- Restrict fluid/sodium intake as indicated

-To reduce further edema

-Administer diuretics as ordered

-To promote fluid excretion

Self-care deficit related to weakness ASSESSMENT S= Ø

NURSING DIAGNOSIS

Self-care deficit related to O= weakness AEB The Patient unkempt hair manifested: untrimmed dirty toenails and -body fingernails weakness -pale palpebral conjunctiva -pale nailbeds -low hemoglobin count (56) -tachycardia -unkempt hair -untrimmed dirty toenails and fingernails - Low hgb count (56) - Low hematocri t count( . 17)

SCIENTIFIC EXPLANATION

OBJECTIVES

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 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 patient’s energy reserve is depleted and experiences weakness. Because of such, the patient is not able to perform self-care

SHORT TERM: After 3º of nursing intervention, the pt will be able to identify individual areas of weakness and needs for selfcare.

LONG TERM: After 2 days of nursing intervention, the pt will perform self-care activities within the level of own ability.

INTERVENTION -Establish rapport

-To gain trust of client

-Determine current capabilities and barriers to participate in self-care

-Identify reasons difficulty self-care

RATIONALE

for in

-Determine hygiene needs and provide assistance as needed with

EXPECTED OUTCOME

the SHORT TERM: the The pt shall have identified -Comprehensive individual functional areas of assessment weakness and included needs for independent self-care, performance of After 3º of basic ADL’s, nursing social intervention activities, sensory abilities and ability to LONG TERM: ambulate The pt shall have -Underlying performed cause affects self-care choice of activities intervention or within the strategies and level of own problem may ability, After be minimized 2 days of nursing -Meets the intervention needs while supporting patient participation

The patient may manifest: -dizziness -drowsiness -lethargy

activities like maintaining appearance at a satisfactory level as evidenced by unkempt hair and as well as poor personal hygiene as evidenced by untrimmed and dirty toenails and fingernails.

activities including care of hair, nails, skin and brushing of teeth -Prepares for -Determine increased individual independence strength and which enhance skills of patient self-esteem -Involve patient in formulation of plan of care at level of ability

-Promote patient/SO participation in problem identification and decision making

-Enhances sense of control and aids in cooperation and maintenance of independence -Enhances commitment to the plan and optimizes outcome

-Conserves -Encourage energy, reduces energy –saving fatigue and techniques enhances pt’s ability to perform tasks -Aids

in

-Shampoo or maintaining style hair as appearance needed and provide or assist with manicure -Reduces risk of -Encourage or gum disease/ assist in routine tooth loss and mouth and enhances oral teeth care daily health -To meet -Encourage nutritional food and fluid demands choices reflecting individual likes especially those rich in iron and vitamin C