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VII. NURSING CARE PLAN

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of retained secretions. obstructive airway diseases in

patients who require more than single bronchodilator.

y Administered low flow oxygentherapy (2L/min) via nasal cannulaas ordered.R: to decrease hypoxemia

POTENTIAL INTERVENTIONS

Dependent

y

Suction secretionsR: to clear airway when excessive

secretions are blocking airway.

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ASSESSMENT DATA

(Subjective & Objective Cues)

NURSING DIAGNOSIS(Problem and Etiology)

GOALS ANDOBJECTIVES

NURSING INTERVENTIONS ANDRATIONALE

Subjective:

dili kayo ko kalihok.. asverbalized by the patient.

Objective:

- Abnormal decrease ofRBC 3.96

- Abnormal decrease ofhemoglobin 11.3

- Abnormal decrease ofhematocrit 34.0

-pale skin

- Heart Rate: 105 bpm

Activity Intolerance (Level

3) related to imbalance

between oxygen supply

and demand

Short term Goals:

After 2hours of thoroughnursing intervention, theclient will be able to:

a. Improve heartrate from 105bpm- 100bpm

b. Use identifiedtechniques toenhance assistivemobility.

INDEPENDENT:

1. Assisted patient in bed to chaiand/or wheelchair mobility.R: To prevent injuries

2. Assisted patient in passive ROMexercises.R: to promote venous return

3. Positioned client in Semi-fowlersposition.R: to promote proper lung

expansion. To maximize oxygenation focellular uptake

4. Encouraged rest periods for clienand avoid exertion on unnecessaryactivities.R: to conserve energyconsumption.

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VII. NURSING CARE PLAN

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ASSESSMENT DATA

(Subjective & Objective Cues)

NURSING DIAGNOSIS(Problem and Etiology)

GOALS ANDOBJECTIVES

NURSING INTERVENTIONS ANDRATIONALE

Subjective:

galisod ko ug libang asverbalized by the patient.

Objective:

> Absent bowel sounds

> Melena

> Altered blood pressure -70/40mmHg

Ineffective tissue perfusion(GI) related to interruptionof arterial blood flow

Short Term:

At the end of 3 hours ofnursing interventions,the patient will be ableto:

a. Improve bloodpressure from70/40 mmHg to130/70mm Hg

b. Demonstratevarious strategiesto improve tissueperfusion going tothe GI.

Long Term:

At the end of 24 hours of

nursing interventions,the patient will be ableto:

a. maintain normalblood pressurewithin the normalrange

ACTUAL INTERVENTIONS

INDEPENDENT:

1. Assisted client in performing range omotion.

R to promote venous return

2. Provide small/easily digested food andfluids as tolerated.R not to overwhelm the integrity of theGI with the presence of food and toallow blood flow.

3. Encourage rest after mealsR: To maximize blood flow to stomachenhancing digestion.

4. Elevate the extremities of the patienwithin the cardiac reserveR to allow venous return

DEPENDENT:

1. Administer dopamine via IV 14cc/hr.R to improve tissue perfusion throughcorrecting hypotension.

POTENTIAL INTERVENTIONS:

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b. Establish bowelsounds. 1. Prepare Client for Nasogastric insertion

R for decompression of the GI.

COLLABORATIVE:

1. Refer to nutritionist: ImbalancedNutrition, less than body requirements.