March 6, 2014

ASSESSMENT
Subjective:
nahihirapan akong
huminga
Objective:
Restlessness
Irritable
Chest X-ray result
(March 3, 2014):
Pulmonary congestion
edema and bilateral
pleural effusion
O2 saturation of 90%
at room air
Respiratory rate of 29
cpm
RBC count of 2.04
x106/uL (4.2
5.40x106/uL) (March
3, 2014)
Hemoglobin of 5.5g/dL
(12 16 g/dL) (March
3, 2014)
Hematocrit of 16.3%
(38 47%)(March 3,
2014)

DIAGNOSIS
Impaired gas exchange
related to imbalance
ventilation perfusion and
altered oxygen-carrying
capacity of blood
secondary to
accumulation of fluids in
the lungs and decreased
hemoglobin level.

PLANNING
Short
Term:
After 1-2 hours of nursing
interventions, the client will
verbalize understanding of
the causative factors that
can aggravate the condition
and appropriate factors that
can help the patient relive
from gas exchange
impairment.

IMPLEMENTATION
1. Monitor skin color and capillary refill.
Determine circulatory adequacy, which is
necessary for gas exchange to tissues.
2. Position client to upright, high Fowler's
position to facilitate ventilation/perfusion
matching. Use High-Fowler's position allows for
optimal diaphragm excursion.
3 .Encourage rest. Rest prevents tissue oxygen
demand and enhances tissue oxygen perfusion.
4. Encourage deep breathing. To reduce
alveolar collapse.

Within 8 hours of nursing

interventions, the client will
report ease in breathing as
evidence by normal O2
saturation of 95 to 100%.

5. Perform chest physiotherapy. To dislodge

the secretions, for easy expectoration
6. Administer 3LPM oxygen as ordered.
Improves gas-exchange decrease work of
breathing.
7. Administer Erythropoietin 5000 IU 2x/ week
Subcutaneous as ordered. To stimulate bone
marrow to produce RBC.
8. Administer 2 units PRBC during HD as
ordered.
9. Administer Folic Acid 5mg/ tablet once a
day as ordered by doctor.
10. Administer Ferrous Tab 3x/day as ordered
by doctor.

March 6, 2014

EVALUATION
Short
Term:
GOAL MET
The client verbalized
understanding of the
causative factors that
can aggravate the
condition and
appropriate factors
that can help the
patient relive from gas
exchange impairment.
GOAL MET
The client reported ease
in breathing as evidence
by normal O2 saturation
of 98%.

ASSESSMENT
Subjective:
para akong nalulunod pag
nakahiga ako
Isang linggo ko na
napapanisin lumalaki at
namamaga ang paa ko
Objective:
Bipedal edema
Positive bilateral rales
Restlessness
Tight skin on both legs
Chest X-ray result
(March 3, 2014):
Pulmonary congestion
edema and bilateral
pleural effusion
Body Weight (March, 4
2014): 97.8Kg

DIAGNOSIS
Fluid volume excess
related to compromised
regulatory mechanism
as manifested by
presence of bipedal
edema, pulmonary
edema, and pleural
effusion.

PLANNING
Short Term:
Within 12 hours of nursing
interventions, the client will
demonstrate behaviours to
monitor fluid status and
reduce recurrence of fluid
excess.
Long Term:
After 2 to 3 days of nursing
interventions, the client will
manifest stabilize fluid
volume, balance I & O and
free from signs of edema.

IMPLEMENTATION
1. Assess or instruct client to monitor weight
daily and consistently, with same scale and
preferably at the same time of day. To facilitate
accurate measurement and to provide a
comparative baseline
2. Assess degree of peripheral edema. Fluid shift in the
tissues as a result of sodium and water retention
3. Record I&O accurately. To monitor elimination of excess
fluid.
4. Reduce constriction of vessels ( avoid
crossing of legs or ankles). To prevent venous
pooling.

EVALUATION
Short Term:
GOAL MET
The client
demonstrated behaviours
to monitor fluid status and
reduce recurrence of fluid
excess.
Long Term:
GOAL MET
The client manifest
stabilized fluid volume,
balance I & O, and free
from signs of edema.

5. Provide adequate activity or position

changes as able. To prevent fluid accumulation in
dependent areas

March 4 session 1,Body

Weight- 91.5kg (post HD)

6. Initiation of femoral catheter. Hemodialysis 2

sessions as ordered. To eliminate excess fluid.

After 12 hours, session 2,

Body weight-89.1kg

7. Initiation of PD catheter. CCPD 1.5/2.3% (1:1)

FV=1L, DT= 30 min x 20 cycles, then CAPD
1.5/2.3% (1:1) FV=1.5L x 6 cycles

After CCPD wt- 88kg

March-6 CAPD wt-87.5kg

March 6, 2014
ASSESSMENT

DIAGNOSIS

Subjective:
mabilis lang ako mapagod

Activity intolerance
related to imbalance
between oxygen
supply and demand as
evidenced by limited
movement.

Objective:
Pallor
Fatigue
Blood pressure of
140/90 mmhg
RBC count of 2.04
x106/uL (4.2
5.40x106/uL) (March 3,
2014)
Hemoglobin of 5.5g/dL
(12 16 g/dL) (March
3, 2014)
Hematocrit of 16.3%
(38 47%)(March 3,
2014)

PLANNING
Short Term:
Within 8 hours of nursing
interventions, the client will
verbalize and utilizes
energy conservation
techniques such as
performing non-essential
procedure, asking
assistance, and taking
adequate rest.
Long Term:
After 2 days of nursing
interventions, the client will
maintain activity level
within capabilities, as
evidenced by absence of
shortness of breath,
weakness, and fatigue.

IMPLEMENTATION
1. Assess clients level of mobility. It aids in defining
what patient is capable of. This is necessary to set realistic
goals.
2. Observe and document response to activity. Close
monitoring serves as a guide for optimal progress of
activity.
3. Encourage adequate rest periods, especially before
ambulation, diagnostic procedures, and meals. To
reduce cardiac workload
4. Refrain from performing non-essential procedures.
To promote rest
5. Anticipate clients needs and keep all things needed
within reach.. To minimize activity
6. Assist with Activity on Daily Living as indicated. To
reduce energy expenditure
7. Encourage verbalization of feeling regarding
limitations. Acknowledge that living with activity
intolerance is both physically and emotionally difficult aids
in coping.
8. Provide emotional support while increasing activity.
To promote a positive attitude regarding abilities.
9. Administer Erythropoietin 5000 IU 2x/ week
Subcutaneous as ordered. To stimulate bone marrow to
produce RBC.
10. Administer 2 units PRBC during HD as ordered.
11. Administer Folic Acid 5mg/ tablet once a day as
ordered by doctor.
12. Administer Ferrous Tab 3x/day as ordered by
doctor.

EVALUATION
Short Term:
GOAL MET
The client verbalized
and utilized energy
conservation
techniques such
performing nonessential procedure,
asking assistance, and
taking adequate rest.
Long Term:
GOAL MET
The client maintained
his activity level within
capabilities, as
evidenced by absence
of shortness of breath,
weakness, and fatigue

March 6, 2014
ASSESSMENT
Subjective:
Masakit yung sugat ko.
(sabay turo sa sugat sa
kaliwang paa niya)
Objective:

Facial Grimace
Restlessness
Discomfort
Limited movement
Pain scale of 8/10.
Bp: 140/90

DIAGNOSIS
Acute pain related to
skin breakdown
secondary to infected
left leg wound

PLANNING

IMPLEMENTATION

EVALUATION

Short Term:

1. Monitor vital signs. To obtain baseline data

Short Term:

Within 30 minutes of series

nursing interventions, the
client will be able to experience
gradual reduction/relief of
pain from the pain scale of
8/10 to 3/10 as evidence by
absence of facial grimace,
restlessness and discomfort.

2. Encourage verbalization of pain. To determine

the intervention.

GOAL MET
The client experienced gradual
reduction/relief of pain from
the pain scale of 8/10 to
3/10 as evidence by
absence of facial grimace,
restlessness and
discomfort.

3. Assist the client if possible. To provide

support.
4. Encourage deep breathing exercises. To
promote comfort and lungs expansion.
5. Encourage to do divertional activities (e.g
watching T.V). To divert attention from pain and
promote comfort.
6. Encourage relatives to perform touch
therapy. To promote comfort
8. Provide calm and quiet environment. To
promote wellness.
9. Give Dolcet 1 tablet PO 3x a day for pain as
ordered. For pain relief.

March 7, 2014
ASSESSMENT
Subjective:
wala akong ganang
kumain at parang
nasusuka pag kumakain
ako

DIAGNOSIS
Potential alteration in
nutrition: less than body
requirement related to
gastrointestinal
disturbance

PLANNING
Short Term:
Within 1 hour of nursing
interventions, the client will
verbalize understanding the
importance of nutrition,
healthy eating habits on
time and relieve nausea

Objective:
Pale conjunctiva and
mucous membrane
Poor muscle tone
Weakness
Nausea
Poor skin turgor >3 sec
Albumin of 23g/L (34
48 g/L) March, 3 2014
Sodium of 133mmol/L
(136 145 mmol/L)
March, 3 2014
Hemoglobin of 5.5g/dL
(13.5 18 g/dL) Mach,
3 2014
Body Weight (March, 4
2014): 97.8Kg

Long Term:
After 3 days of nursing
interventions, client will
practice healthy eating
habits based on calories
requirement

IMPLEMENTATION
1. Assess or instruct client to monitor weight
daily and consistently, with same scale and
preferably at the same time of day. To facilitate
accurate measurement and to provide a comparative
baseline
2. Explain the importance of adequate nutrition
and fluid intake such as eat food rich in vitamin
D, green leafy vegetables, Calcium, protein and
drink at least one litter of fluids a day. Client may
have inadequate or inaccurate knowledge regarding
the contribution of good nutrition to over all wellness.
3. Keep strict documentation of intake, output,
and calorie count. To make an accurate nutritional
assessment and maintain client safety.
4. Ensure that client receives small, frequent
feedings, including a bedtime snack, rather than
three larger meals. Large amounts of food may be
objectionable, or even intolerable, to the client.
5. Prevent or minimize unpleasant odors or sight.
May have a negative effect on appetite and eating.
6. Check the food of the client during meals. To
verify if the food serve by dietary unit is correct
7. In collaboration with dietitian, determine
number of calories required to provide adequate
nutrition and realistic (according to body
structure and height) weight gain. This information
is necessary to make an accurate nutritional program
for the client.
8. Monitor laboratory values, and report
significant changes to physician. Laboratory
values provide objective data regarding nutritional
status.

EVALUATION
Short Term:
GOAL MET
The client verbalized
understanding and
importance of nutrition,
healthy eating habits on
time and relieve nausea as
evidence by good appetite
Long Term:
GOAL MET
By frequent observation,
the client was able practice
healthy eating habits
based on calories
requirement of the
dietitian.

March 7, 2014
ASSESSMENT
Subjective:
hindi ako makatulog ng
maayos dahil kinakapos
ako ng hininga at
sumasakit minsan ung
sugat ko
Objective:

Restlessness
Fatigue
Irritability
Eye bags
Orthopnea

DIAGNOSIS
Disturbed sleeping
pattern related to
abnormal physiological
status secondary to
difficulty of breathing
and pain discomfort.

PLANNING
Short Term:
Within 1 hour of nursing
interventions, client will be
able to identify individually the
appropriate interventions to
promote sleep like sleeping in
an upright position, listen to
soft music and take a warm
bath before sleeping.
Long Term:
After 3 to 5 days of nursing
interventions, the client will
achieve optimal amount of sleep
as evidenced by absence of
restlessness, fatigue
and irritability.

IMPLEMENTATION
1. Assess clients usual sleep patterns, and
compare with current sleep disturbance. To
ascertain intensity and duration of problems.
2. Provide bedtime care such as changing
linens or gown, back massage and encourage
usual bedtime routines such as washing face
and hands, and brushing teeth. To promote
physical comfort.
3. Provide dark and quiet environment. To
promote sleep.
4. Position the client to comfortable position/
upright position. To facilitate ventilation and lung
expansion.
5. Provide soft music and calm television
program. To enhance relaxation.
6. Instruct to avoid heavy meals, alcohol,
caffeine, and chocolates. Though hunger can
also keep one awake, gastric digestion and
stimulation from caffeine can disturb sleep.
7. Explore other sleep aids (warm bath and
drinking milk) To promote wellness.
8. Administer oxygen as ordered. Improves gasexchange decrease work of breathing.
9. Give Dolcet 1 tablet PO 3x a day for pain as
ordered. For pain relief.

EVALUATION
Short Term:
GOAL MET
The client identified
individually the appropriate
interventions to promote
sleep like sleeping in an
upright position, listen to
soft music and take a
warm bath before
sleeping.
Long Term:
GOAL MET
The client achieved optimal
amount of sleep as
evidenced by absence of
restlessness, fatigue
and irritability.

March 6, 2014
ASSESSMENT
Subjective:
nahihirapan akong
huminga lalo na pag
nakahiga ako, para akong
nalulunod
Objective:
Restlessness
Irritable
Positive bilateral
rales
Use of accessory
muscles to breath
Dyspnea
Chest X-ray result
(March 3, 2014):
Pulmonary
congestion edema
and bilateral pleural
effusion
O2 saturation of
90% room air
Respiratory rate of
29 cpm

DIAGNOSIS
Ineffective Breathing
pattern related to
decrease lung
expansion secondary
to fluid accumulation.

PLANNING
Short Term:
Within 1 hour of nursing
interventions, client will be
able to verbalize
understanding and
demonstrate proper deep
breathing technique to
facilitate proper
oxygenation

IMPLEMENTATION
1. Monitor skin color and capillary refill.
Determine circulatory adequacy, which is
necessary for gas exchange to tissues.
2. Position client to upright, high Fowler's
position to facilitate ventilation/perfusion
matching. Use High-Fowler's position allows for
optimal diaphragm excursion.
3. Encourage slower/deeper respirations, use
of pursed-lip technique. To assist client in taking
control of the situation.

EVALUATION
Short Term:
GOAL MET
Client verbalized
understanding and
demonstrate proper deep
breathing technique to
facilitate proper
oxygenation
Long Term:

Long Term:
After 2-3 days of nursing
interventions, client will be
free of dyspnea and
establish normal breathing
pattern as manifested by
absence of restlessness,
dyspnea and normal O2
sat of 95% to 99%

4. Maintain calm attitude while dealing with

client and significant others. To limit level of
anxiety.
5. Provide /encourage use of adjuncts, such as
incentive spirometer. To facilitate deeper
respiratory effort.
6. Administer 3LPM oxygen as ordered.
Improves gas-exchange decrease work of
breathing.

GOAL MET
Client is free of dyspnea
and establish normal
breathing pattern as
manifested by absence of
restlessness, dyspnea and
normal O2 sat of 95%

March 7, 2014
ASSESSMENT

DIAGNOSIS

Subjective:
2 weeks na yang sugat ko
pero mabagal gumaling

Impaired wound
healing secondary to
infection as evidence
by pus discharge,
redness and foul odor

Objective:

Infected wound on
left leg with pus
discharge, redness,
and foul odor
Wound GS/CS
Moderate heavy
growth of 1)
Enterobacter
agglomerans and 2)
Entercoccus faecium

PLANNING
Short Term:
After 2 hours of nursing
intervention the patient will be
able to gain knowledge in
infection control as evidenced
by discussing the proper
wound care, signs of
infections and importance of
proper hand washing.
Long Term:
After 3 days of nursing
intervention, the client will
achieve timely wound
healing and will be free of
sign and symptom related to
infection as evidenced by
absence of fever, dry and
intact wound site.

IMPLEMENTATION
1. Assess signs and symptoms of infection
especially temperature. Fever may indicate infection.
2. Discuss to patients the following signs of
infection -redness, swelling, increased pain or
purulent drainage on the site and fever. To
impart to the patient when the wound become
infected and when to sought medical care.
3. Emphasize the importance of hand washing technique.
It serves as an first line of defines against infection.
4. Maintain aseptic technique when changing
dressing/caring wound. Regular wound dressing
promotes fast healing and drying of wound.
5. Keep area around wound clean and dry. Wet
area can be lodge area of bacteria.
6. Demonstrate and allow return demonstration
of wound care. To know if the patient really
understand the principle of proper wound care
7. Give Ciprofloxacin 500mg/tab 2x a day for 7
days. Co-Amoxiclav 625mg/tab 3x a day for 7
days as orderd by doctor.

EVALUATION
Short Term:
GOAL MET
After 2 hours of nursing
intervention the patient
was able to gain
knowledge in infection
control as evidenced by
discussing the proper
wound care, signs of
infections and importance
of proper hand washing.
Long Term:
GOAL MET
After 3 days of nursing
intervention, the client was
able to achieved timely
wound healing and was
free of sign and symptom
related to infection as
evidenced by absence of
fever, dry and intact wound
site.

March 6, 2014
ASSESSMENT
Subjective:
nurse parang may lagnat
ung pasyente as
verbalized by the relatives
Objective:
Body Temperature:
38.3C
Heart Rate: 102bpm
Respiratory rate:
26cpm
Warm to touch
Diaphoresis
03/03/14 Wound
GS/CS: Moderate
heavy growth of
1.) Enterobacter
agglomerans
2.) Entercoccus
faecium,
(03/03/14)
WBC:16.81x 106/uL
Neutrophil: 85.4%

DIAGNOSIS
Hyperthermia
related to bacterial
infection

PLANNING
Short Term:
After 4 hours of
nursing interventions,
the client will be able
to demonstrate
temperature within
normal range (36.537.5C) and be free of
signs of fever like
warm to touch,
diaphoresis.

IMPLEMENTATION
1. Assess and monitor clients temperature and note for
presence of chills/ profuse diaphoresis; also note for degree
and pattern of occurrence. Temperature 38.9C 41C may
suggest acute infectious disease process. A sustained fever may
be due to pneumonia or typhoid fever while a remittent fever may
be due to pulmonary infections; and an intermittent fever may be
caused by sepsis or tuberculosis.
2. Educate client of signs and symptoms of hyperthermia
and help him identify factors related to occurrence of fever;
discuss importance of increased fluid intake to avoid
dehydration. Providing health teachings to client could help
client cope with disease condition and could help prevent further
complications of hyperthermia.
3. Adjust and monitor environmental factors like room
temperature and bed linens as indicated. Room temperature
may be accustomed to near normal body temperature and
blankets and linens may be adjusted as indicated to regulate
temperature of client.
4. Remove excess clothing and cover. These decrease
warmth and increase evaporating cooling.
5. Encourage client to increase fluid intake. Water regulates
body temperature.
6. Maintain bed rest. Reduce metabolic demand and oxygen
consumption.
7. Educate and advise relative to do tepid sponge bath
when patient feels hot. Make sure that armpits and groins
were included in doing tepid sponge bath. To reduce increase
temperature. Teaching the relatives on tepid sponge bath will
help in knowing what to do in case the patient temperature
increases.
8. Administer Paracetamol 500mg for fever PRN as ordered
by doctor.

EVALUATION
Short Term:
GOAL MET
The client was able to
demonstrate a
decreased in body
temperature from
38.3C to 37.1C and
no signs of fever.