Nursing Diagnosis:

 Ineffective airway clearance related to productive cough

INTERVENTIONS RATIONALE

 Assess the airway patency  To check the effectivity of the airway & to plan for further

management

 Elevate the head part of the bed/change position q 2h  To enhance drainage of/ventilation to different lung

segments

 Encourage deep-breathing and coughing exercise  To mobilize secretions

 Monitored the fluid intake  To help liquefy secretions and not to severe the edema

 Instruct to have proper clothing, not too tight and not too  To provide warm body/environment

loose

Nursing Diagnosis:
 Acute pain related to edema
INTERVENTIONS RATIONALE

 Monitor vital signs  Because vital signs are altered in acute pain experienced

 Acknowledge patient’s verbalization of pain & allow him  Pain is subjective experience of a person that no other one
to describe it can felt about it

 Perform pain assessment each time occurs  To rule out worsening of underlying condition/developing
complication

 Elevate edematous extremities, change position frequently  To reduce tissue pressure and risk of skin breakdown

 Provide quiet environment  To promote ventilation and limits external stimuli

 Administer Spironolactone 50mg itab TID P.O. as  For the treatment for edema
prescribed by the physician
B. Actual Nursing Management

S “Bug-at lang akong tiil kay nanghupong naman ko.”

As verbalized by the patient

 Edema
O  Oliguria
 Restlessness

Fluid volume excess related to Glomerulonephritis

A

Long term:
At the end of 2 days, pt. will be able to lessen or diminished the
symptoms of glomerulonephritis that produces excessive fluid.
P
Short term:
At the end of 8 hours, the pt. will be able to reduce the excessive
fluid volume.

1) Monitor vital signs especially temperature

 To check & assess for infection since the pt. has a higher
risk
2) Monitor intake & output
I  To monitor & check fluid volume & prevent dehydration
3) Elevate the edematous extremities
 To reduce tissue pressure & risk in skin breakdown
4) Place in a semi-fowlers position, change position frequently
 To facilitate movement of diaphragm & improve
respiratory effort
5) Administer furosemide 1 ampule every 12h as prescribed by the
physician
 For the treatment of edema

E At the end of 8 hrs, the pt reduces the excess fluid in his body thru
excretion of stored fluids.
July 21, 2007

S= Ø
O= Received pt. in sitting position, awake, conscious and coherent with IV out, with
moderate facial edema; with vital signs recorded as follows: T= 37.1; PR= 82bpm; RR=
28bpm; BP= 110/90 mmHg.

A= Fluid volume excess r/t failure of regulatory mechanism AEB facial edema.
P= After 4˚ of nsg. intervention, SO will verbalize understanding health teaching on
contributing factors.

I=
 Established rapport
 Monitored vital signs
 Recorded urine output and fluid intake
 Provided health teachings to SO about the appropriate diet for the patient.
 Explained to the SO the importance of decrease intake of salty foods and fluid
restriction.
 Facilitated Tepid Sponge Bath (TSV) and instructed SO of TSB.
 Provided well ventilated environment
 Provided comfort measures
 Kept back dry

E= Goal met AEB SO can verbalize understanding fluid restriction and decrease intake
of salty foods.

July 26, 2007

S= Ø
O= Received pt. in lying on supine position, awake, conscious and coherent with on
going IVF # 4 D5. 0.3 NaCl 500 mL x KVO, infusing well in right hand @ 450 cc; with
vital signs recorded as follows: T= 38.4; PR= 94bpm; RR= 20bpm; BP= 120/100 mmHg.

A= Hyperthermia r/t inflammatory process.

P= After 4˚ of nsg. intervention, patient’s temperature will be decrease from 38.4˚C to
73˚C.

I=
 Established rapport
 Monitored vital signs especially temperature
 Monitored urine output and fluid intake
 Provided health teachings to SO about the appropriate diet for the patient.
 Explained to the SO the importance of decrease intake of salty foods and fuild
restriction.
 IVF dislodge and removed

E= Goal met AEB patient’s temperature decreased from 38.4˚C to 37˚C.