Mary Katleene D.

Cueto
Assessment Kahapon, mukhang pang-elepante yung paa ko as verbalized by the patient Bipedal edema is evident No IVF is noted Initial VS is as follows: T- 36.8C P- 90bpm R-18cpm BP-140/90mmHg Diagnosis Impaired skin integrity Related to presence of edema secondary to fluid retention Planning At the end of the shift, the client will be able to: >verbalize understanding of treatment regimen done to lessen edema Intervention VS obtained, monitored and recorded Morning care done (changed bed linens, encouraged hygiene, etc) Change wound dressing Rationale To obtain baseline data To maintain physical cleanliness

BSN3A
Evaluation Patient manifests willingness to do recommended activities and verbalizes understanding on the therapeutic regimen.

Elevate feet

To prevent further complications and to reassess improvements of the wound To reduce fluid retention in feet

Health teaching given as follows: >Emphasized on Low Salt, Low Fat diet >Simple exercise daily >Increase fluid intake >Increase fiber intake like pineapple and green leafy vegetables >Void immediately when urge is felt >Comply to medications

To prevent fluid retention and hypertension To remain hydrated Prevent straining

To prevent fluid retention

Mary Katleene D. Cueto

Assessment Masakit po paglumulunok as verbalized by the patient Pain scale of 9 out of 10 IVF of #2 D5LR @900 level regulated at 4142 gtts/min, patent and infusing well On soft to liquid diet Blood count results: >WBC: 14.7x106/L >Neutrophil: 0.80 >Lymphocyte: 0.20 Initial VS is as follows: T- 36.1C P- 92bpm R-32cpm BP-120/80mmHg Facial grimace is evident when swallowing Diagnosis Acute pain Related to infection in tonsils and pharynx As evidenced by facial grimace and change in appetite Planning At the end of the shift, the client will be able to: Intervention VS obtained, monitored and recorded Rationale To obtain baseline data

BSN3A
Evaluation Patient manifests willingness to do recommended activities and scaled 8 out of 10

verbalize relief of Morning care done pain from 9 to at least (changed bed linens, 6 out of 10 encouraged hygiene, etc) Bactidol gargle done Health teaching given as follows: >Emphasized on Soft to Liquid diet like porridge, soup, etc.) >Maintain a quiet environment >Perform DBE >TSB for fever >Comply to medications

To maintain physical cleanliness

To reduce infection

So patient will eat only tolerated foods

To keep rested

To alleviate pain To evaporate heat in the body