immunologic disorder.ncp

8/8/2019 Immunologic Disorder.ncp

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Immunologic Disorder

Assessment Diagnosis Planning Intervention Rationale EvaluationSubjective:

Nahihirapan akong

huminga as

verbalized by the

patient.

Objective:

y Cyanosisy Cold clammy skiny Restlessy Ineffective coughy (+) adventious

breath sound

Ineffective airway

clearance related to

retained secretions in

the bronchi

Short term:

After 2 hours of

nursing intervention

the client will be able

to maintain patency

and clear breath

sounds.

y Establishedrapport

y Vital signsmonitored and

recorded.

y IVF regulated atdesired rate.

y Suctionedsecretions PRN

y Placed the patientin orthopneic

position

y Elevated HOB

y Demonstrated tothe patient how to

perform deepbreathing

exercises

y Due med given(bronchodilators)

y Referred to the

y To gain the clientstrust and

cooperation.

y To obtain thebaseline data of

the patient

y To decreasesecretion in the

bronchi

y To maintain patentairway

y To take advantageto the gravity

decreasedpressure on the

diaphragm

y To mobilized thesecretion

y To moisen thesecretion and to

expectorate

easier.

y To medicallymanage

complication and

After series of nursing

intervention the

patient has maintained

airway patency and

cleared breath sounds.

Goal met.


2/15

NOD for any

abnormality of the

body.

for prevention

Assessment Diagnosis Planning Intervention Rationale Evaluation

Subjective:

aray masakit pa din

and tiyan ko as

verbalized by the

patient.

Objective:

y Pallory With guarding

behavior on the

abdomen

y With pain scale of6/10

y V/So RR 21cpmo BP

140/100

Acute abdominal pain

related to post surgery

at the lower abdomen

After 8 hours of


the patients pain will

be lessen from the

pain scale of 6/10 to3/10.

y Establishedrapport.

y Monitored andrecorded V/S


y Noted the locationand intensity of

pain through the

use of pain scale.

y Observed for nonverbal cues such as

guarding behavior

and facial grimace.

y Monitored skinintegrity on thesurgical site.

y Provided thepatient with

comfort measures

such as positioning

the patient

comfortably on

y To gain patientstrust and

cooperation.

y To obtain thebaseline data ofthe patient.

y To assess for thepresence of

infection and to

have a baselinedata on the

intensity of pain.

y To provide thepatient with the

non

pharmacological

pain management.

After 8 hours of


the patients pain has

decrease from the pain

scale of 6/10 to 4/10.Goal partially met.


3/15

bed, ensured

adequate

ventilation andcalm environment.

y Assisted thepatient in using

hot/cold

compress.

y Assisted the SO inproviding soft

massage.y Instructed the

patient to use

diversional

activities such as

listening to calm

music, reading and

watching tv.

y Due meds given.y Needs attended. y To control thepain.

Addisonians Crisis

Assessment Diagnosis Planning Intervention Rationale EvaluationRisk for injury r/t

acute renal

insufficiency

secondary to stressor

(infection, surgery,

trauma or emotional

stress)

After a series of


the patient will

verbalize the

understanding of

individual factors that

contributes to the


y Monitored andrecorded v/s

y IVF regulated at


cooperation.

y To establishedthe baseline data

of the patient.

y Failure to

After a series of


the patient has

verbalized the

understanding of

individual factors that

contributes to the


4/15

possibility of injury. desired rate.

y Performedthoroughassessment

regarding safety

issues when

planning for

patients care.

y Ascertainpatientsknowledge or

safety needs at

home and

hospital settings.

y Assessedpatients mood,

coping abilitiesand personality

style.

y Assessed clientsmuscle strength

and body

coordination.

y Provided thepatient ofhealthcare within

a culture of

safety.

y Positionedpatient

comfortably on

bed.

accurately assess

or intervene or

refer these issuescan place the

patient at

needless risk and

creates

negligence for the

health care

provider.

y To prevent suchinjury at homeand hospital.

y May affectpatients ability

to protect self

and influence

choice of

intervention andhealth teachings.

y To identify riskfor fall.

y To prevent errorsresulting to

patients injury,fatigue and

anger.

y To promotecomfort and

adequate rest.

possibility of injury.


5/15

y Raised the siderails of the bed.

y Providedadequate lighting.y Due meds given.y Needs attended.

DiabetesMellitus

Assessment Diagnosis Planning Intervention Rationale EvaluationRisk for fluid volume

deficit r/t polyuria

and dehydration.

After a series of


the patient will

identify individual risk

and appropriate

interventions.


y Monitored andrecorded v/s


y Noted thepossible

condition that

may lead to fluid

volume deficit

such as DM.

y Noted thepatients level of

consciousness.

y Monitored andrecorded I and O

y To gain thepatients trust

and cooperation.

y To establish thebaseline data of

the patient.

y To help preventdehydration.

y To evaluate theability to express

needs.

y To ensureaccurate picture

After a series of


the patient has

identified individual

risk and appropriate

interventions to

manage dehydration

and polyuria.


6/15

y Weighted thepatient regularly.

y Assessed skinturgor and oral

mucousmembrane.

y Establishedpatients needs

for fluid

replacement.

y Advised thepatient to limit

intake of fluidthat has a diuretic

effect such as

caffeine and

alcohol.

y Encouraged avariety of fluids in

small frequent

amounts.y Provided a calm

and a well

ventilated

environment.

y Due meds given.y Needs attended.

of fluid loss.

y To determinetrends andchanges in

muscle built of

the patient.

y To monitor fordehydration.

y To preventdehydration.

y To avoid to muchfluid loss.

y For fluidreplacement.


7/15

Ulceratice Colitis


mga 2 days ng tubig

ang dumi ko as

verbalized by the

patient.

Objective:

y Febrile of 38Cy Pallory Body weaknessy Cold clammy skiny Poor skin turgory Dry oral mucosay Passage of 10-20

liquid stools per

day

Deficient fluid volume

r/t to severe diarrhea

After 8 hours of


the patient will

maintain fluid volume

at functional level as

evidenced by the

decrease in number

of bowel movements.


y v/s monitoredand recorded.


y Weighted thepatient regularly.y Administered

fluid and

electrolyte

replacement.

y Noted the colorand consistency

of the stool.

y Instructed thepatient not to

take dark colored

food.

y Limited thepatients intake of

caffeine.

y Provided thepatient with diet

high in protein,


cooperation.

y To establish thebaseline data of

the patient.

y To determineweight loss.y To prevent severe

dehydration.

y To assess forbleeding/

y Which has adiuretic effect.

y To regain energyand for tissue

repair.

y To avoid loss offluid through

perspiration.


8/15

carbohydrate

such as rice,

meat, egg andfish.

y Provided a wellventilated

environment.

y Positioned thepatientcomfortably on

bed.

y Provided thepatient adequate

time to rest.


y For comfort andrelaxation.

Glummerulonephritis


Subjective:nahihilo ako at

sobrang sama ng

pakiramdam ko as

verbalized by the

patient.

Objective:

Ineffective renaltissue perfusion

interruption of blood

flow as evidenced by

elevation in BUN.

After 8 hours ofnursing intervention

the patient will

demonstrate

increased tissue

perfusion.

y Establishedrapport.y v/s monitored

and recorded.


y To gain patientstrust andcooperation.

y To obtainpatients baseline

data.

After 8 hours ofnursing intervention

the patient has

demonstrated

increase in tissue

perfusion.

Goal met.


9/15

y BP 140/100y Headachey Pallory Body malaisey Tea colored uriney Edema on the

lower extremities

y Determinefactors thatcontribute to the

condition such as

Glummeruloneph

ritis.

y Identifiedchanges r/t

peripheral

alteration incirculation such

as altered

mentation, v/s,

changes in skin

turgor and

edema.

y Determined usualvoiding patternsand compare

with current

situation.

y Weighted thepatient regularly.

y Assisted thepatient inpositioning the

lower extremities

than the upper

extremities.

y Demonstrated tothe patient the

y To be able toperform optimumnursing care for

the patient.

y To determine thedegree of

damage to tissue.

y To be able toidentify theabnormal voiding

pattern of the

patient.

y To note thechanges in

weight.

y For propervenous return.

y To establish aregular exercise


10/15

use of mild to

moderate

exercise such aswalking for 15-30

minutes.


pattern.

Rheumatiod Arthritis


Subjective:

sumasakit ang likod

ko kapag gumagalaw

sa kama as

verbalized by thepatient.

Objective:

y Pallory With facial

grimace

y With guardingbehavior on theaffected part

y Body malaisey With minimal

movements and

needs the

assistance of SO

upon moving on

Impaired bed mobility

r/t to pain

After 2 hours of


the patient will be

able to identify

techniques toenhance bed

mobility.




y Determinedpatient level of

mobility.

y Demonstratedand encouraged

the patient to

perform deep

breathing

techniques.


cooperation.

y To established abaseline data ofthe patient.

y To assess thefunctional activity

of the patient.

yy To prevent lung

atelectasis.

After a series of


the patient has

identified techniques

to enhance bedmobility.


11/15

bed

y Unable to sit onbed

y Pain scale of 7/10

y Taught thepatient the

proper range ofmotion and self

care activities

while on bed.

y Assisted thepatient in turning

side to side and in

sitting for at least15 minutes.

y Provided thepatient with calm

and well

ventilated

environment.


y To immobilizedthe body parts

and performsimple exercises

while on bed.

y To prevent bedsores.

y To proved thepatient adequate

time to rest.

Hay Fever


Nahihirapan ako

huminga as

verbalized by the

patient.

Objective:

Ineffective breathing

pattern r/t allergic

reaction


intervention the

patient establish

effective respiratory

pattern as evidenced

by the absence of

cyanosis.




y To gain patienttrust and

cooperation.

y To obtain thepatients baseline

data.


intervention the

patients has

established effective

respiratory pattern as

evidence by the

absence of cyanosis.


12/15

y Cyanosisy Cold clammy skiny Nasal flaringupon inhalationy Sneezingy Runny nosey Nasal congestiony Used of accessory

organs during

breathing

y

y Acultated thechest to assess

for breathsounds.

y Noted the depthof respiration and

type of breathing

pattern.

y Administered O2at desired rate.

y Instructed thepatient to takeslower and

deeper

respiration

y Monitoredpatients pulse

oximetry as

indicated.y Provided the

patien with a

calm and a well

ventilated

environment.

y Positioned thepatient

comfortably onbed.

y Instructed the.patient to avoid

persons with

URTI and

crowded palces.

y Due meds given

y To establish abaseline data of

the patient.

y To aid inbreathing.

y To verifymaintenance and

improvement in

O2 saturation.y To promote rest

and comfort.

Goal met.


13/15

y Needs attended.

Cancer


Subjective:

kelan babalik ang

boses as the patient

wrote

Objective:

y Inability to speaky Angery Irritabley Frustration

Impaired vocal

communication r/t to

removal of vocal

cords

After 8 hours of


the patient will

indicate

understanding

communication

problems and ways of

handling it.




y Reviewedpreoperative

discussion

regarding loss ofvoice using

anatomical

drawings to aid in

the discussion.

y Provided call lightor bell at the bed

side of the

patient.

y Providedalternative way of

communication

such as paper and

pencil, slate

board, letter or

y To gain patienttrust and

cooperation.

y To obtain thebaseline data of

the patient.

y Reinforcepreoperative

teaching and

encourage

understanding ofcommunication

problem.

y To reassure thepatient that the

nursing staff will

hear if the patientneeds them.

y Allow patient toexpress needs

and concern.

After 8 hours of


the patient has

indicated signs of

understanding on

handling his

communication

problems.

Goal met.


14/15

picture board and

cell phone.

y Positionedpatient

comfortably on

bed.

y Due meds given.y Needs attended

y To promotecomfort and

adequate rest.


15/15

STI College Sta. CruzSta. Cruz, Laguna

NCM 104

Submitted by: Rovee Renz Rubio

BSN 401-B

Sumitted to: Mrs. Janette B. Labit

immunologic disorder.ncp

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