dili pa-sure

8/7/2019 dili pa-sure

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X. Ideal Nursing Care Plan

1. Activity Intolerance r/t Imbalance between oxygen supply (delivery) and demand possibly evidence by weakness and

fatigue.

Independent:

1. Assess pt. ability to perform normal tasks

intervention.

Influences choice of interventions/ needed assistance

2. Monitor BP, pulse, respirations Cardiopulmonary manifestations result from attempts by the

heart and lungs to supply adequate amounts of oxygen to

the tissues

3. Recommend quiet environment, bed rest if

indicated.

Enhances rest to lower bodys oxygen requirements and

reduces strain on the heart and lungs

4. Elevate head of bed as tolerated Enhances lung expansion to maximize oxygenation for

cellular uptake

Collaborative:

5. Monitor laboratory studies eg. Hbg/Hct. AndRBC count, arterial blood gases (ABGs)

Identifies deficiencies in RBC compounds affecting oxygentransport and treatment needs/ response to therapy.

2. Acute Pain r/t chemical burn of gastric mucosa

Independent:

1. Provide small, frequent meals Small meals prevent distention and the release of gastrin.

2. Identify and limit foods that create discomfort. Studies indicated pepper is harmful and coffee (including

decaffeinated)can precipitate dyspepsia.

3. Assist with active and passive range of motion

exercises.

Reduces joint stiffness, minimizing pain/ discomfort.

4. Provide frequent oral care and comfort

measures e.g., back rub, position change.

Halitosis from stagnant oral secretions is unappetizing and

can aggravate nausea. Gingivitis and dental problems may

arise.

Collaborative:

5. Provide and implement prescribed dietary

modifications.

Client may receive nothing by mouth (NPO) initially.

X I. Actual Nursing Plan

1.

S Gibati kog kakapoy maam.

O

- Weak in appearance

- Bedrest- Dyspnea- Pallor

A Activity Intolerance r/t Imbalance between oxygen supply (delivery) and demand possibly

evidence by weakness and fatigue.

P

At the end of 3- 4hours of nursing interventions, the pt. will be able to improve condition and

participate in desired activities.


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I

E At the end of 3- 4hours of nursing interventions, the pt. was able to improve condition and


2.

S Hapdos ug sakit ako tiyan.

O

- Weak in appearance

- Guarding behavior- Facial grimace- Pain scale: 7 of 10

A Acute Pain r/t chemical burn of gastric mucosa possibly evidenced by abdominal guarding,facial grimacing

P

At the end of 2- 3hours of nursing interventions, the pt. will be able to verbalize relief of pain and

demonstrate relax body posture.

I

Independent:

1. Assessed pt. pain reports: location;

pain scale; frequency

This will indicate need for various interventions

and may signal possible complications.

2. Advised pt to eat small, frequent

meals

Small meals prevent distention

3. Identified and suggested pt to limit

foods that create discomfort.

Studies indicated pepper is harmful and coffee

(including decaffeinated) can precipitate

dyspepsia.

4. Encouraged verbalizations of feelings

and thoughts

This can reduce anxiety and fear thereby

reducing the perception of pain and discomfort

Collaborative:

5. Provided and implemented prescribeddietary modifications.

Client may receive nothing by mouth (NPO)initially.

E At the end of 2- 3 hours of nursing interventions, the pt. was able to verbalize relief of pain and

demonstrate relax body posture.

3.

S Binhud akong tiil ug dili kayo ko kalakaw ug layo.

O

- Weak in appearance- Bedrest- Decreased performance- Pallor

A Fatigue related to poor physical condition


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P

At the end of 6- 7hours of nursing interventions, the pt. will be able to improve condition and


I

E At the end of 6- 7 hours of nursing interventions, the pt. was able to improve condition and


4.

S Binhud akong tiil ug dili kayo ko kalakaw ug layo.

O

- Weak in appearance- Bedrest- Decreased performance

- With O2 inhalation

A Impared Gas Exchange related to reduced RBC

P

At the end of 2 days of nursing interventions, the pt. will be able to demonstrate improvedventilation/oxygenation with clear breath sounds

I

E At the end of 6- 7 hours of nursing interventions, the pt. was able to improve condition and


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