ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE THEORY EVALUATION

Cues: Excess fluid Short Term Independent: Independent: Goal was

volume related Goal: partially met.
to compromised 1. Established 1. To gain the
Subjective: regulatory After the 8 hours Rapport patient's trust and After 8 hours of
mechanism as of nursing cooperation. nursing
evidenced by intervention, the intervention, the
Objective: blood pressure patient will be 2. Monitor and 2. To assess patient will be
changes, able to record vital signs precipitating and able to:
BP: 130 / 60 mmHg pulmonary causative factors
congestion, and ● Reduce ● Reduce
- Difficulty in electrolytes reoccure 3. Record accurate 3. Accurate I&O is reoccurren
breathing imbalances nce of intake and output. necessary for ce of fluid
fluid Include “hidden” determining fluid excess
excess fluids, such as replacement needs ● Stabilize
● Stabilize intravenous (IV) and reducing the risk fluid intake
fluid antibiotic additives, of fluid overload. and output
intake liquid medications, Low urine output volume
and ice chips, and less than 400 mL/24 and
output frozen treats. hr may be first normal
volume indicator of acute vital signs.
and failure, especially in
normal a high risk patient.
vital
signs. 4. Monitor urine 4. Measures the
specific gravity kidney’s ability to
Long-term concentrate urine.
Goal:
5. Monitor the 5. Tachycardia and
After 24 hours of heart rate and hypertension can
nursing blood pressure, if occur because of (1)
intervention, the available failure of the kidneys
patient will be to excrete urine, (2)
able to excessive fluid
 resuscitation during
● efforts to treat
hypovolemia or
hypotension, and (3)
changes in the renin-
angiotensin system,
which helps regulate
long-term blood
pressure and blood
volume.

6. Accurate lung 6. Fluid overload

and heart sounds may lead to
pulmonary edema
and HF, as
evidenced by
development of
adventitious breath
sounds and extra
heart sounds.

7. Measure 7. May indicate

abdominal girth for increase in fluid
changes retention

8. Observe skin 8. To evaluate

mucous membrane. degree of fluid
excess

9. Restrict sodium 9. To lessen fluid

and fluid intake if retention and
indicated overload.

Dependent:
 1. Administer 1. Given early in
furosemide as oliguric phase of AKI
ordered. in an effort to
convert to diuretic
phase, flush the
tubular lumen of
debris, reduce
hyperkalemia, and
promote adequate
urine volume.

2. Administer 2. May be given to

amplodipine as treat hypertension by
ordered. counteracting effects
of decreased renal
blood flow and/or
circulating volume
overload.

Collaboration:

1. Review 1. To monitor fluid

laboratory data like and electrolyte
BUN, creatinine, imbalances.
serum electrolyte.

RISK IN INFECTION RELATED TO SMOKING

ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE THEORY EVALUATION

Subjective: Risk for Short Term:

Infection Independent: Independent: Hildegard Goal was
Peplau:
 related to After 8 hours of
n\a smoking nursing 1. Establish rapport 1. To gain patients Interpersonal partially met.
intervention, the trust and Relations Theory
Objective: patient will be cooperation.
able to
Neutrophils: 70% 2. Assess causative Short Term:
(30-66%) ● White or contributing “An interpersonal
blood factors such as 2. Client may have process of
Eisonophil: 10% underlying disease that therapeutic
cell After the 8 hours
(0-3%) illness. directly impacts interactions
count of nursing
and immune system between an
Monocyte: 7 % (e.g., cancer, individual who is intervention, the
(3 - 6 %) differenti patient will be
al will AIDS, sick or in need of
3. Encourage the autoimmune health services able to
almost patient to reduce - Have a
reach disorder) or may and a nurse
or limiting be weakened by especially normal
the smoking. limit of
normal any disease educated to
Condition. recognize, respond white
limit. Dependent: blood cell
● Verbaliz to the need for
help.” and
e 1. Administer differentia
understa antibiotics such 3. Smoking caused l blood
nding of as piperacillin - increasesd blood count
limiting tazobactam and leukocytes, Ida Jean - Verbalize
or fluconazole as neutrophils, Orlando: the
reducing ordered. lymphocytes, and Deliberative understand
smoking monocytes. Nursing Process ing of
Theory limiting or
Long term: Dependent: reducing
smoking.
After 24 hours 1. This drugs are
of nursing Collaborative: used to combat “The nurse’s role Long term:
intervention, the most of the is to find out and
1. Monitor
patient will be
able to meet the patient’s After 24 hours of
laboratory microbial immediate needs nursing
● Remain studies, such as pneumonias for help.” intervention, the
free of the following: patient will be
infection, CBC, noting Collaborative: able to
as whether WBC
evidence count falls or 1. Decreased - Remain
d by sudden changes numbers of normal free of
absences occur in or mature WBCs infection
of signs neutrophils, can result from the as
and eisonophil and disease process, evidenced
symptom lymphocytes. compromising the by
s of immune response absences
infection. and increasing risk og signs
of infection. and
symptoms
of
infection.