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Subjective: Ineffective tissue perfusion Short term goals: Independent: Goals partially met.
(Renal) related to increased blood The patient was
“…. Dili man kayo ko ka-ihi..” concentration After 8 hours of thorough 1.) Monitor urine output on a regular able to verbalized
nursing intervention, the schedule. the urge to urinate
client will be able to: R – To come with a baseline data. and able to reduce
2.) Restrict client’s fluid intake pitting edema from
Objective:
R – To avoid severity of the problem. 4mm to 2mm but
Increased serum creatinine 3.) Apply patient’s bladder cold packs failed to achieve a
a.) Verbalize the urge to
level (1.27) R – To stimulate the urge to urinate. normal blood
urinate
Pitting Edema on both lower 4.) Let the patient hear the running water from glucose level within
b.) Decrease blood
and upper extremities (4mm) the faucet. the range of 80 –
glucose level from
Decreased urine output R – To stimulate the urge to micturate. 110mg/dL
321mg/dL within
5.) Encourage patient to avoid foods that
Increased HGT level of 321 normal range of 80 – (111mg/dL)
mg/dL triggers increase of blood glucose level.
110 mg/dL
R – to maintain normal serum glucose level.
oliguria c.) Reduce pitting
edema from 4mm to Dependent:
2mm
1.) Administer medication (Furosemide), as
ordered
R – To stimulate urination.
Long term goals:
2.) Administer medications (insulin), as
a.) Completely eliminate ordered.
presence of pitting R – Helps in lowering down blood glucose
edema. level.
b.) Maintain normal
blood glucose level of
Collaborative:
80 – 110mg/dL
1.) Refer to the dietician for his Diabetic diet.
VII. NURSING CARE PLAN
ASSESSMENT DATA NURSING DIAGNOSIS GOALS AND OBJECTIVES NURSING INTERVENTIONS AND RATIONALE EVALUATION
(Problem and Etiology)
(Subjective & Objective Cues)
Subjective: Ineffective tissue perfusion Short term goals: Independent: Goals partially met.
(Peripheral) related to increased The patient was
“… dugay kayo ga-ayo akong samad sa blood viscosity secondary to After 8 hours of thorough 1.) Assist client in frequent ambulation, when able to reduce
tiil…” hyperglycemia nursing intervention, the possible pitiing edema from
client will be able to: R – to enhance venous return 4mm to 2mm and
2.) Elevate the legs when sitting, avoiding improved skin color
a.) Decrease blood sharp angulations of the hips or knees.
Objective: at the wund site
glucose level from R – to promote proper venous return from pallor to
321mg/dL within 3.) Position patient in a high back rest
Increased HGT level of 321 pinkish but failed
normal range of 80 – R – to increase gravitational blood flow.
mg/dL to achieve normal
110 mg/dL 4.) Apply patient’s bladder cold packs
Pitting edema on both lower blood glucose level
b.) Improve the capillary R – To stimulate the urge to urinate.
and upper extremities (4mm) of 80 – 110mg/dL
refill from 4 seconds 5.) Let the patient hear the running water from and failed to
Prolonged capillary refill of 4 to 3 seconds.
seconds. the faucet. improve capillary
c.) Reduce pitting R – To stimulate the urge to micturate.
Pallor in the punctured wound edema from 4mm to
refill of 4seconds to
at the right foot 3 seconds.
2mm Dependent:
d.) Improve skin color at
the wound site. 3.) Administer medications (insulin), s ordered.
R – helps in lowering down blood glucose
Long term goals: level.
4.) Administer 2 ampules of amino acid (IV).
a.) Completely eliminate R – to promote faster healing of the
presence of pitting wound.
edema.
b.) Maintain normal Collaborative:
blood glucose level of
80 – 110mg/dL 1.) Refer to the dietician for his Diabetic diet.
2.) Increase protein intake of the patient.
R – Protein promotes faster healing of the
wounds.
VII. NURSING CARE PLAN
ASSESSMENT DATA NURSING DIAGNOSIS GOALS AND OBJECTIVES NURSING INTERVENTIONS AND RATIONALE EVALUATION
(Problem and Etiology)
(Subjective & Objective Cues)
Dependent: