AssessmentNursing OutcomesNursing InterventionsSymptom ManagementAdvance Care PlanningSpiritual CareCo Morbid ManagementEvaluation

SUBJECTIVE

The patient verbalize I felt sickly hot and weak. The patient verbalize slight tingling sensation when peeing. Throat pain

OBJECTIVE

Elevated temperature(38.9 degree Celsius) Blood in urine Weak in appearance Oxygen saturation:88% Dyspnea Pain scale:10 Weight: From 60 kls.-55 kls.Latest:57 kls.

The patient will report absence of pain or a decrease

The patient will participate in ADLs and therapeutic activities without limitation by pain.

Thepatients will report less respiratory distress and will participate in ADLs with diminishing dyspnea or fatigue. The patients weight will be maintained or weight loss minimized. a.The patient will not develop a pressure sore.

The patient will be independent in self-care (feeding, bathing, toileting, mobility). The patient will not harm self or others during hospitalization. The patient will get out of bed, transfer, or ambulate.PAIN assessment for the presence and characteristics of pain (location, quality, and intensity on a 0-to-10 scale, and its aggravating and relieving factors) administering analgesics and adjuvant agents and evaluating their efficacy advocating for around-the-clock dosing (versus as-needed dosing) of analgesics for chronic pain, preferably by the oral route evaluating and preventing untoward side effects (e.g., constipation from chronic opiate or tricyclic antidepressant use); using nonpharmacologic techniques as appropriate, such as assuring adequate periods of undisturbed rest, positioning, heat and cold applications, warm baths, massage, and other relaxation techniques educating the patient and family regarding (a) reporting pain at its onset and before it becomes disabling, (b) how to use the 0-to-10 scale to rate pain intensity, (c) reporting uncontrolled or inadequately controlled pain, (d) the medications used to control pain and for side effect management, and (e) nonpharmacologic measures to relieve pain.

IMPAIRED GAS EXCHANGE respiratory assessment (e.g., reporting any increased shortness of breath, cough, or chest pain) and pulse oximetry administering and titrating oxygen to a physician-prescribed oxygen saturation level administering antibiotics and monitoring for side effects administering opioids (e.g., morphine) for palliation assisting with ADLs organizing care to provide maximal periods of rest repositioning the patient as necessary to facilitate excursion and promote postural drainage educating the patient regarding purse-lipped breathing to decrease tachypnea and anxiety preparation for a pulmonary diagnostic work-up.

IMBALANCED NUTRITION LESS THAN BODY REQUIREMENT

assessment and ongoing monitoring of weight, intake and output, ability to feed oneself, ability to swallow, symptoms interfering with food and fluid intake, orthostatic V.S., skin turgor, and cultural food preferences feeding the patient and encouraging oral intake administering intravenous hydration, appetite stimulants, antidiarrheals, and antiemetics as ordered advising the physician of uncontrolled symptoms that interfere with intake and advocating for work-up and/or symptomatic control obtaining consultations from a dietician for specific diet prescriptions educating the patient regarding adequate fluid intake (at least 2 to 3 liters/day); the role of nutrition in acute illness recovery; and the clinically significant drug-nutrient interactions encouraging family and friends to bring the patient's favorite foods.

IMPAIRED SKIN INTEGRITY

assessing pressure ulcer risk factors, condition of the skin, and presence of wound(s), as well as wound size, location, condition of surrounding tissue, evidence of granulation, odor, amount and color of drainage, and current skin and wound care regimens; initiating pressure ulcer prevention activities if the patient is at risk (e.g., establishing a turning schedule if the patient is unable to turn in bed, providing pressure-relieving mattresses or special beds, and instituting a bladder training program as appropriate) consulting with a dietician or nutritionist to determine the need for nutritional support consulting with the nursing wound care specialist, if available, regarding appropriate wound cleaning and dressing plan educating the patient or in-home caregiver regarding the skin and wound care regimen advocating for rehabilitation consultation, if appropriate, to increase the patient's mobility consulting with the social worker or discharge planner regarding the patient's continuing wound care needs after discharge.

SELF CARE DEFICIT assessing the patient's ability to perform ADLs (self-care ability), motor and sensory function, bowel and bladder management, and other symptoms interfering with patient's ability to manage ADLs assisting with those areas the patient cannot manage independently obtaining needed supplies and equipment advocating for aggressive symptom management recommending rehabilitation consultation as appropriate identifying the patient's continuing care needs, including the need for placement after discharge educating the patient/caregiver regarding ADL management - that is, bathing, transfers (e.g., from sitting to standing, from bed to chair), using such assistive devices as a cane or walker, eating, bowel and bladder management, and medication management.

PSYCHOSOCIAL CONCERNS/ INEFFECTIVE COPING assessing and monitoring on an ongoing basis for the concerns such as patients with dual and triple diagnoses (HIV infection, substance use, and psychiatric illness) will require more intensive interventions. determining previous coping strategies, beliefs and concerns regarding illness, previous hospital experiences, and ability to communicate needs and to ask for help determining access to basic services creating an environment of acceptance and respect for human dignity determining the patient's knowledge of illness and treatment while providing accurate information appropriate to a patient's understanding encouraging honest, consistent communication between hospital staff and the patient and the patient's self-identified support system referring the patient to a social worker for assistance with basic services (e.g., housing, food) and community resources (e.g., delivered meals, volunteer services for chores or support) referring the patient to counselors and/or a chaplain for psychosocial support and spiritual counseling if indicated monitoring for any maladaptive response, such as suicidal ideation, verbal threats, or assaultive behavior; setting explicit, appropriate behavioral limits; protecting the patient, self, and others (calling security if there is a threat of violence); and consulting with a physician for psychiatric evaluation and or chemical restraints providing patient opportunities for choice as much as possible; referring the patient with a history of substance use to a substance abuse counseling service if the patient agrees and such a service is available, monitoring for signs and symptoms of intoxication and or withdrawal, advocating for symptom control, and relying on protocol to manage the person who is using drugs or alcohol in-house for patients expected to die in the hospital, activating the nursing standard of care for the adult dying patient and subsequent section concerning the dying patient).

RISK FOR FALL/ INJURY assessing for fall risk factors (e.g., confusion, mobility problems, incontinence, orthostatic hypotension) informing all other caregivers about patients at risk for fall instructing the patient and family to request assistance when the patient is transferring (e.g., from bed to chair) or ambulating keeping the call light, bedpan, urinal, and belongings within the patient's reach keeping the bed in low position with side rails up increasing direct observations and, if necessary, moving the patient's room nearer to the nurses' station offering frequent assistance with ADLs using safety devices (e.g., bed alarms) consulting with the physician regarding need for sedation or physical restraints if the patient is a danger to himself or herself and one-on-one observation is impossible; providing the necessary care, support, and monitoring if physical restraints are used.

FEVER Drink plenty of fluids (water, juice, non-caffeinated beverages) at least 6-8glasses per day. Get plenty of rest to conserve energy and avoid fatigue. Take tablets or other medicine as directed by your doctor or nurse to lower your fever or high temperature. If you are taking antibiotics, be sure to take all of the medication (complete thecourse). Take your temperature when you feel sick. If it is more than 99F (3 8C), take itagain in 3 to 4 hours. Avoid sponge baths while using fans as these may cause you to have chills andshivering. Shivering causes the temperature to rise even higher and should be avoided when possible. Keep the skin dry and covered.

FATIGUE Do small tasks to avoid fatigue. Drink energy drinks (cg. Gatorade. Lucozade) and take oral rehydration solution. Rise slowly when waking up sit up first. Drink solution from boiled beetroot. Chew 2 to 3 cloves of garlic three times a day. When cooking vegetables ensure that they are not overcooked as vitamins get destroyed. Try relaxing or stress-reducing activities such as deep-breathing exercises, meditation, personal quiet time, massage. listening to music or relaxation tapes, getting involved in activities (e.g. volunteer work) taking walks Eat more of the following foods: oatmeal and other whole grain cereals, fruit and raw vegetables, whole grain baked goods yoghurt and low or non-dairy products. Limit the following foods: sugary & fast foods and other high fat foods. Reduce alcohol and caffeine intake, as these tend to make you sluggish later. Develop a routine of going to bed in the evening and getting up each morning at the same time. A good night s sleep can help you think more clearly. Naps are okay. But keep them short and early in the day. Avoid or reduce your use of alcohol and other mood-altering non-prescription drugs (eg.. cocaine, speed. dagga. glue)

NIGHT SWEATS Keep your skin warm and dry. Wear light cotton clothing and use fewer blankets. open windows to allow ventilation and fresh air. Drink plenty of fluids (water. juice. non-caffeinated beverages) at least six to eight glasses per day. Drink cold water. Sponge yourself with tepid water. Change your clothing and linen regularly. Place a towel over your pillow in cases of profuse sweating. After you wake up. towel dry, apply lotion to your skin, and then put on dry clothes. Have a change of clothes or dry linen nearby. especially when sweats occur at night. Talk to your doctor or nurse about taking any medication before going to bed at night

SHORTNESS OF BREATHE Try relaxing or stress-reducing activities such as deep-breathing exercises, meditation, personal quiet time, massage, listening to music or relaxation tapes, getting involved in activities (e.g. volunteer work), taking walks, leisure reading taking a warm bath. Tal-Chi etc. Sit up straight to expand the chest as much as possible. Take a walk daily at your own pace in your home or outside. Muscles that are weak from lack of activity or exercise can make you feel short of breath with any movement. Routine exercise can reduce your shortness of breath related to muscle weakness. Try to use these breathing strategies. The key is to inhale and breathe out slowly where possible. Pursed Lips Breathing: Breathe in normally through the nose while counting s-l-o-w-l-y to two; purse lips, as if about to whistle: breathe out slowly through your pursed lips (take twice as long as you did to breathe in - count slowly to four). Controlled or Paced Breathing: This is the use of Pursed Lips Breathing with activities which make you winded, such as climbing stairs, walking quickly or lifting heavy objects. The key is to inhale slowly (at rest if possible) and exhale through pursed lips while performing the work. Focus on breathing out slowly and evenly.

WEIGHT LOSS Eat and drink a lot. Eat frequent, small meals. Take multivitamins. Add garlic to your food. Keep track of your weight by weighing yourself or by looking for changes in the way your clothes fit. Cook and eat with friends or family to make meals enjoyable. Eat high-protein high-calorie foods and snacks such as peanut butter and jelly, sandwiches, crackers and cheese, pudding and yoghurt. Add instant breakfast drinks, milk shakes or other supplements to your diet and drink them any time of the day. Take a multivitamin with at least 100% Recommended Daily Allowance (RDA)every day. Keep foods that are easy to prepare on hand (e.g.. frozen and canned foods). Eat fresh thins and vegetables.

Health care providers can assist patients and families by (a.)discussing the benefits of health care and social support programs, unemployment insurance, workers compensation, pension plans, insurance, and union or association benefits;

(b.)emphasizing the importance of organizing information and documents so that they are easily located and accessible;

(c.)suggesting that financial matters be in order, such as power of attorney or bank accounts, credit cards, property, legal claims, and income tax preparation;

(d.) discussing advance directives or power of attorney for care and treatment, as well as decisionsrelated to the chosen setting for dying;

(e.) discussing the patients wishes regarding their deathWhom does the patientwant at the bedside? What rituals are important to the dying patient? Does the patient wish an autopsy? What arrangements does the patient want regarding the funeral services and burial? Where donations in remembrance should be sent? It is important to realize that these issues should be discussed at relevant stages in the persons illness, in a manner that is both respectful to the patients wishes and strengths and that promotes the patients sense of control over his or her life and death.

Health care providers must also understand the concept of competency, a state in which the person is capable of taking Iegal acts, consenting or refusing treatment, writing a will orPower of attorney.

In assessing the patients competency, the health provider must a) question whether the decision maker knows the nature and effect of the decision to be made.(b.)understands the consequences of his or her actions, (c.)determine if the decision is consistent with an individual's life history, lifestyle, previous actions, and best interests.When an individual is competent, and in anticipation of the future loss of competency, he or she may initiate advance directives such as a living will and/or the designation of a health core proxy, who will carry out the patients health care wishes or make health care decisions in the event that the patient becomes incompetent.

The patient may also give an individual the power of attorney regarding financial matters and care or treatment issues, advance directives include the patients decisions regarding such life-sustaining treatments as cardiopulmonary resuscitation, use of vasoactive drips to sustain blood pressure and heart rate, dialysis, artificial nutrition and hydration, and the initiation or withdrawal of ventilator support.

The signing of advance directives must be witnessed by two individuals who are not related to the patient or involved in the patients treatment.

Individuals who are mentally competent can revoke at any lime their advance directives. If a patient is deemed mentally incompetent, state statutes may allow the court to designate a surrogate decision-maker for the patient.Facilitating and Conducting Prayers

The nurse will facilitate prayers for patients by finding space and time for praying.

The patient will strongly expressed prayers to help them in enhancing hope and bringing harmony among mind, soul, and body, and consequently in attaining serenity and inner healing.

Reading of Holy Scriptures

The nurse may sit with her patients and reads, and refers to relevant passages from the Bible or encourage the patient to read bible.

The patient will thought that reading Holy Scriptures promoted hope and peace.Pastor Consultation

Organizing a visit from a pastor (or priest) so that the patient will be blessed.

Encouraging Patients to Trust God/Supreme Being/Creator.

The nurse may give an advice to the patient about having a strong faith for the patient's healing.

Demonstration of Love, Compassion, and Forgiveness

The nurse may emphasize the goodness of love, compassion and forgiveness to the patient. Taking interest and listening actively and being present were important aspects of a human interaction. Demonstrating empathy and sympathy helps patients cope with illness.

Maintaining and Demonstrating Moral and Ethical Behaviour

The Nurse should demonstrate moral and ethical behaviours such as being polite, honest, faithful, and respectful of individuals regardless of religious beliefs were considered spiritual care interventions.

Counseling and Reassurance

The nurse will counsel and provide reassurance to patients as significant spiritual care interventions. (eg..making a patient pain free, and reducing patients fears related to surgery)TUBERCULOSISDiagnostic: Smear-negative, culture-positive TB for advanced immunosuppression. Bronchoscopy with bronchoalveolar lavage & transbronchial biopsy may be useful in the evaluation of persons with abnormal chest radiograph imagery when sputum smear results are negative.

Treatment: The first 2 months of treatment is often referred to as the intensive phase, and typically entails the use of 4 drugs--rifampin (or other rifamycin), Isoniazide, pyrazinamide, and ethambutol--followed by 4 months (called the continuation phase) with rifampin and Isoniazide alone.as long as the regimen contains Isoniazide and a rifamycin for the duration of TB treatment. As for HIV-uninfected individuals, the standard recommendation for HIV-coinfected individuals with pulmonary TB is a 6-month course of treatment, with extension to 9 months for patients with cavitary lung disease and culture positivity at 2 months of TB treatment.

PNEMUCCOCAL INFECTION

Diagnostic: the sputum Gram's stain- there are few epithelial cells, many polymorphonuclear leukocytes, predominant bacterial morphology. Blood cultures are very specific and clinicians should obtain them in all HIV-1 infected patients suspected of having serious pneumococcal infection.

Treatment: HIV-1 seropositive patients with moderate to severe pneumococcal pneumonia should be hospitalized and treated with parenteral antimicrobial agents. For hospitalized patients with documented penicillin-sensitive (MIC