XI.
NURSING MANAGEMENT
Nsg. Dx:
Decreased cardiac output r/t vascular
resistance secondary to hyper ension
Cues:
increased BP, RR and decreased AR and PR.
Treatment: Amplodipine 5mg, Losartan 50 mg
Interventions:
- Have pt. lie down or in a comfortable position
-Monitored intake and output
-Have a patient use a commode or urinal.
-Provided a restful environment by minimizing
controllable stressors and unnecessary
disturbances.
Admitting Dx: Chronic Renal Failure 2o Hypertensive
Nsg. Dx: Altered peripheral tissue perfusion
r/t decrease circulating hemoglobin
Cues:increased BP, RR and decreased AR
and PR. HgB=46
Laboratories: Hematology
Treatment: Blood transfusion
Interventions:
- Slow the pace of care. Allow the pt. extra time
to carry out activities.
-Provided peaceful environment
-Encouraged to eat serve meals
-Monitor post BT reactions.
CONCEPT MAP
Nsg. Dx:
Disturbed sleep pattern r/t fear of therapeutic
regimen [blood transfusion]
Cues:
Dark-big eyebags; Weak and pale; Drowsy;
verbalized was not able to sleep the entire night
Interventions:
-Keep environment quiet for sleeping, eliminate
noise.
-Perform nursing procedures all at the same time if
possible before patient to go to sleep.
-Adjust lighting by providing curtains.
C/C: Difficulty of Breathing
Nephrosceloris
Nsg. Dx:
Impaired gas exchange r/t ventilation-
perfusion imbalance.
Cues:increased BP, RR and decreased AR
and PR. HgB=46
Laboratories:Hematology
Interventions:
- Position pt in Semi-fowler’s position
-Encouraged increased fluid intake
-Encouraged/Assisted the pt. to eat small meals
frequently.
-Provided and encourage peaceful environment to
rest and sleep.
Nsg. Dx: Imbalance nutrition: less than body
requirement r/t inadequate food intake as evidenced
by lack of appetite.
Cues:
Lack of interest in foods; Weak and pale
Pale conjunctiva; Consumed ¼ of served meals
Treatment: Heraclene 3 mg
Interventions:
- Position the pt in a comfortable position.
-Provide relaxing environment while eating.
-Allow patient to choose foods she likes.
-Provide companionship or assist the pt while eating
to encourage nutritional intake
Nsg. Dx:
Impaired urinary elimination r/t
urinary retention
Cues:
Urine volume/fluid output= 100 cc within 8
hours; + edema noted on both cheeks
Verbalized difficulty in voiding
Treatment: Furosemide, 60 mg and
Rowatinex 2 caps
Interventions:
Provide an environment that encourages
toileting; and administer meds as ordered.