ASSESSMENT Subjective cue: Katol akong panit dapit sa akong paa, as verbalized by the patient.
NURSING DIAGNOSIS Impaired skin integrity related to changes in pigmentation secondary to mapping of rashes in lower extremities.
GOALS AND OBJECTIVES Short term: After 20-30 minutes of nursing interventions, the patient will be able to: Stabilize blood pressure reading Reduce BP from 160/100mmHg to 130/90mmHg Have a stable peripheral pulses Minimize episodes of dysnea Long term: After 2 days of nursing interventions, the patient will be able to: Participate in activities that reduce the workload of the heart Identify early signs of hypertension and seek help appropriately
NURSING INTERVENTIONS AND RATIONALE Independent: Monitor vital signs to serve as baseline data Reduce environmental stressors that can contribute to hypertension Position the client side to side every 2 hours to enhance circulation of the blood to the peripheries Position the client to semi-fowlers position to enhance lung expansion Encourage client to perform deep breathing exercises Explain proper dietary intake to reduce risks of complications regarding hypertension Teach home monitoring of weight, pulse rate, and BP to detect changes and allow for timely intervention Dependent: Administer supplemental oxygen for proper tissue function Administer antihypertensive medications for proper management of hypertension Collaborative: Assists in special procedures to maintain proper nursing care
EVALUATION Short term: Goals met. After 20-30 minutes of nursing interventions, the patient: Stabilized blood pressure reading Reduced BP from 160/100mmHg to 130/90mmHg Stabilized peripheral pulses Minimized episodes of dysnea Long term: Goals met. After 2 days of nursing interventions, the patient: Participated in activities that reduce the workload of the heart Identified early signs of hypertension and seek help appropriately
Objective cues: Rashes on both lower extremities
ASSESSMENT Subjective cue: Galisud ko ug bakod tungod sa akong tiyan, as verbalized by the patient.
NURSING DIAGNOSIS Impaired bed mobility related to increased abdominal girth secondary to fluid accumulation in the peritoneum.
GOALS AND OBJECTIVES Short term: After 20-30 minutes of nursing interventions, the patient will be able to: Verbalize understanding of situation and risk factors, and safety measures. Long term: After 16 hours of nursing interventions, the patient will be able to: Maintain position of function and skin integrity as evidenced by absence of rashes or any assigns of pressure ulcer.
NURSING INTERVENTIONS AND RATIONALE Independent: Ascertain that client is placed in best bed for situation (e.g., correct size, support surface, and mobility functions) to promote ease in mobility and enhance environmental safety. Utilize bed and mattress positioning settings to assist movements. Reposition client in good body alignment to provide comfort and prevent injury. Observe skin for reddened areas or shearing injury. Stretch out mattress to reduce friction and maintain skin integrity. Instruct client and significant others in methods of moving client relative to specific situations and mobility needs. Assist with activities of hygiene and toileting, as indicated. Dependent: Administer Furosemide as prescribed.
EVALUATION Short term: Goal met. After 20-30 minutes of nursing interventions, the patient was able to: Verbalized understanding of situation and risk factors, and safety measures. Long term: Goal met. After 16 hours of nursing interventions, the patient was able to: Maintained position of function and skin integrity as evidenced by absence of rashes or any assigns of pressure ulcer.
Objective cues: Impaired ability to move from supine to sitting/rising up 73cm abdominal girth Deviation of spine to the left
