Professional Documents
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S: Ineffective Septick shock Long outcome: Assess the To get tha baseline Long
nahihirapan po Airway Client will respiratory rate, data outcome:
ako huminga,hindi po Clearance maintain an rhythm, and depth, Client
ako makahinga ng related Systemic effective breathin and note for maintained
maayos as verbalized Bronchospas antigen- g pattern, as changes an
by the patient m as antibody evidenced by effective bre
evidence by immune relaxed breathing athing
O: nasal flaring, response to a at normal rate pattern, as
Nasal flaring increase RR. foreign and depth and Assess the Life-threatening evidenced
Increaserespiratory restlessness substance absence of clients anxiety level situations such as by relaxed
rate adventitious . shock can produce breathing at
Restlessness breath sounds. elevated levels normal rate
Peripheralcyanosis Smooth muscle of anxiety and depth
(nailbeds) contraction Short outcome: and absence
Cold clammyskin After 5-10 Monitor oxygen Pulse oximetry is of
(hands) minutes, the saturation and used to monitor adventitious
Massive patient will be arterial blood oxygen saturation. breath
vasodilation and able to breath in gasses. It should be kept at sounds.
increased with ease least 90% or
capillary trigger higher. Short
outcome:
Instruct the client to Focus breathing After 5-10
Progress to breathe slowly and may help calm the minutes, the
rapidly to deeply. client, and the patient able
respiratory increase tidal to breath in
distress volume facilitates with ease
improved gas
exchange.
Difficulty of Position the client
breathing upright. This position
provides
oxygenation by
Ineffective promoting
airway maximum chest
clearance expansion
S: Excess fluid Renal disorder Patient display Accurately record Accurate Patient
sobrang dami nap o volume impairs appropriate intake and output monitoring of I&O displayed
ng ihi niya pero and related to glomecular urinary output (I&O) noting to is necessary for appropriate
onti lang naman po ng compromised filtation that with specific include hidden determining renal urinary
tubig na pinapainom regulatory resulted to fluid gravity/laboratory fluids such as IV function and fluid output with
sa kaniya as mechanism overload with studies near antibiotic additives, replacement needs specific
verbalized by the possibly fluid volume normal; stable liquid medications, and reducing risk of gravity/labor
patient evidenced by excess weight, vital signs frozen treats, ice fluid overload atory studies
intake greater within patients chips. near normal;
Objective: than output, Hydrostatic normal range; stable
Prescence of generalized pressure is the and absence of Monitor urine Measures the weight, vital
urinary edema,weigh higher than the edema. specific gravity. kidneys ability to signs within
catheter t gain, usual pushing concentrate urine patients
Input of 200 changes in excess fulids normal
Output of 450 metal into the Weigh daily at Daily body weight range; and
ml status,restles interstitial space same time of day, is best monitor of absence of
sness on same scale, fluid status edema.
with same
Since fluid are equipment and
not reabsorbed clothing.
at the venous
end fluid Assess skin, face, Edema occurs
become over dependent areas primarily in
load thats there for edema. dependent tissues
is excess fluid Evaluate degree of of the body,
volume edema (on scale of (hands, feet,
+1+4) lumbosacral area).
Tachycardia and
Monitor heart rate hypertension can
(HR), BP, and occur because of
JVD/CVP. failure of the
kidneys to excrete
urine