Assessment Subjective: Namamaga ang ibang parte ng katawan ko. As verbalized by the client.

Objective: - Intake greater than output - Weight gain - Edema - 140/100mmHg - 103 bpm

Diagnosis Fluid Volume Excess related to compromised regulatory mechanism as evidenced by intake greater than output; edema; weight gain and as verbalized by the client namamaga ang ibang parte ng katawan ko.

Planning Within the 3 days of nursing intervention the client will be able to decrease weight; edema and normalized intake and output and a verbalization of Hindi n masyadong namamaga itong katawan ko.

Implementation Independent: - Record accurate intake and output (I&O). Include hidden fluids such as IV antibiotic additives, liquid medications, ice chips, frozen treats. Measure gastrointestinal (GI) losses and estimate insensible losses, e.g., diaphoresis.

Rationale -Low output (less than 400 mL/24 hr) may be first indicator of acute failure, especially in a high-risk patient. Accurate I&O is necessary for determining renal function and fluid replacement needs and reducing risk of fluid overload. Note:Hypervolemia occurs in the anuric phase of ARF. -Daily body weight is best monitor of fluid status. A weight gain of more than 0.5 kg/day suggests fluid retention. -Edema occurs primarily in dependent tissues of the body, e.g., hands, feet, lumbosacral area.

Evaluation After 3 days of nursing intervention the client was able to decrease weight; edema and normalized intake and output and a verbalization of Hindi n masyadong namamaga itong katawan ko. And the goal was met.

-Weigh daily at same time of day, on same scale, with same equipment and clothing. -Assess skin, face, dependent areas for edema. Evaluate degree of edema (on scale of +1+4).

Patient can gain up to 10 lb (4.5 kg) of fluid before pitting edema is detected. Periorbital edema may be a presenting sign of this fluid shift because these fragile tissues are easily distended by even minimal fluid accumulation -Monitor heart rate (HR), BP, and JVD/CVP. -Tachycardia and hypertension can occur because of (1) failure of the kidneys to excrete urine, (2) excessive fluid resuscitation during efforts to treat hypovolemia/hypotension or convert oliguric phase of renal failure, and/or (3) changes in the reninangiotensin system. Note: Invasive monitoring may be needed for assessing intravascular volume, especially in patients with

poor cardiac function. -Auscultate lung and heart sounds. -Fluid overload may lead to pulmonary edema and HF evidenced by development of adventitious breath sounds, extra heart sounds. (Refer to ND: Cardiac Output, risk for decreased, following.) -May reflect fluid shifts, accumulation of toxins, acidosis, electrolyte imbalances, or developing hypoxia. -Helps avoid periods without fluids, minimizes boredom of limited choices, and reduces sense of deprivation and thirst

-Assess level of consciousness; investigate changes in mentation, presence of restlessness. -Plan oral fluid replacement with patient, within multiple restrictions. Intersperse desired beverages throughout 24 hr. Vary offerings, e.g., hot, cold, frozen.

Dependent: -Administer Drugs (e.g. Furosemide) as prescribed.

- Given early in oliguric phase of ARF in an effort to convert to non-oliguric phase, flush the tubular lumen of debris, reduce hyperkalemia, and promote adequate urine volume. -Kidneys may be able to return to normal functioning, preventing or limiting residual effects.

Collaborative: -Correct any reversible cause of ARF, e.g., replace blood loss, maximize cardiac output, discontinue nephrotoxic drug, relieve obstruction via surgery.

Assessment Subjective: Parang Bumibilis ang pagtibok ng puso ko.. As verbalized by the client. Objective: - 103 bpm - 140/100mmHg - Edema

Diagnosis Decreased cardiac output related to fluid overload as evidenced by tachycardia with a heart rate of 103 bpm and as verbalized by the patient parang bumibilis ang pagtibok ng puso ko.

Planning Implementation Within 30 minutes of Independent: nursing intervention - Monitor BP and HR. the client will be able to decreased heart rate within the normal range and will verbalized Hindi n mabilia ang pagtiok ng puso ko.

Rationale - Fluid volume excess, combined with hypertension (often occurs in renal failure) and effects of uremia, increases cardiac workload and can lead to cardiac failure. In ARF, cardiac failure is usually reversible. - Changes in electromechanical function may become evident in response to progressing renal failure/accumulation of toxins and electrolyte imbalance. For example, hyperkalemia is associated with peaked T wave, wide QRS, prolonged PR interval, flattened/absent P wave. Hypokalemia is associated with flat T wave, peaked P wave, and

Evaluation After 30 minutes of nursing intervention the client was able to decreased heart rate within the normal range and has verbalized Hindi n mabilia ang pagtiok ng puso ko. And the goal was partially met.

-Observe ECG or telemetry for changes in rhythm

appearance of U waves. Prolonged QT interval may reflect calcium deficit. - Auscultate heart sounds. -Development of S3/S4 is indicative of failure. Pericardial friction rub may be only manifestation of uremic pericarditis, requiring prompt intervention/possibly acute dialysis. - Pallor may reflect vasoconstriction or anemia. Cyanosis is a late sign and is related to pulmonary congestion and/or cardiac failure. - Neuromuscular indicators of hypocalcemia, which can also affect cardiac contractility and function.

-Assess color of skin, mucous membranes, and nailbeds. Note capillary refill time.

-Investigate reports of muscle cramps, numbness/tingling of fingers, with muscle twitching, hyperreflexia.

- Maintain bedrest or encourage adequate rest and provide assistance with care and desired activities. Dependent: - Administer medications as indicated: Inotropic agents, e.g., digoxin (Lanoxin);

- Reduces oxygen consumption/cardiac workload.

- May be used to improve cardiac output by increasing myocardial contractility and stroke volume. Dosage depends on renal function and potassium balance to obtain therapeutic effect without toxicity. - During oliguric phase, hyperkalemia is present but often shifts to hypokalemia in diuretic or recovery phase. Any potassium value associated with ECG changes requires intervention. Note: A serum level of 6.5 mEq or higher constitutes a medical emergency.

Collaborative: - Monitor laboratory studies (e.g. Potassium, etc.)

Assessment Subjective: Medyo nahihirapan akong huminga. As verbalized by the client. Objective: - Cyanosis - 35cpm

Diagnosis Ineffective airway clearance related to inhalation of chemicals as evidenced by tracheobronchial obstruction; cyanosis; respiratopry rate of 35cpm and a verbalization of Medyo nahihirapan akong huminga.

Planning Within 30 minutes of nursing intervention the client will have no obstruction; no cyanosis; respiratory rate within the normal range and a verbalization of hindi na ako nahihirapang huminga.

Implementation Independent: - Obtain history of injury. Note presence of preexisting respiratory conditions, history of smoking.

Rationale - Causative burning agent, duration of exposure, and occurrence in closed or open space predict probability of inhalation injury. Type of material burned (wood, plastic, wool, and so forth) suggests type of toxic gas exposure. Preexisting conditions increase the risk of respiratory complications.

Evaluation Within 30 minutes of nursing intervention the client has no obstruction; no cyanosis; respiratory rate within the normal range and a verbalization of hindi na ako nahihirapang huminga. And the goal was

- Assess gag/swallow - Suggestive of reflexes; note drooling, inhalation injury. inability to swallow, hoarseness, wheezy cough. - Monitor respiratory rate, rhythm, depth; note presence of pallor/cyanosis and carbonaceous or pinktinged sputum. - Tachypnea, use of accessory muscles, presence of cyanosis, and changes in sputum suggest developing respiratory distress/pulmonary

edema and need for medical intervention. - Investigate changes in behavior/mentation, e.g., restlessness, agitation, confusion. - Although often related to pain, changes in consciousness may reflect developing/worsening hypoxia. - Promotes optimal lung expansion/respiratory function. When head/neck burns are present, a pillow can inhibit respiration, cause necrosis of burned ear cartilage, and promote neck contractures - Promotes lung expansion, mobilization and drainage of secretions.

- Elevate head of bed. Avoid use of pillow under head, as indicated.

- Encourage coughing/deepbreathing exercises and frequent position changes.

-Suction (if necessary) with extreme care, maintaining sterile technique.

- Helps maintain clear airway, but should be done cautiously because of mucosal edema and inflammation. Sterile technique reduces risk of infection. - Increasing hoarseness/decreased ability to swallow suggests increasing tracheal edema and may indicate need for prompt intubation. - O2 corrects hypoxemia/acidosis. Humidity decreases drying of respiratory tract and reduces viscosity of sputum.

-Promote voice rest, but assess ability to speak and/or swallow oral secretions periodically.

Dependent: - Administer humidified oxygen via appropriate mode, e.g.,face mask as ordered.

Collaborative: - Prepare for/assist with intubation or tracheostomy, as indicated.

-Intubation/mechanical support is required when airway edema or

circumferential burn injury interferes with respiratory function/oxygenation.

Assessment Subjective: Nauuhaw ako sobra sobra. As verbalized by the client. Objective: - Cyanosis - 35cpm

Diagnosis Fluid Volume deficit related to burns as evidenced by general burn wounds; thrist; dry mucous membranes and a verbalization of Nauuhaw ako sobra sobra.

Planning Within 30 minutes of nursing interventions the client will be able to have moist mucous membranes; no thrist and a verbalization of Hindi n ako nauuhaw kagaya ng dati.

Implementation Independent: - Estimate wound drainage and insensible losses

Rationale - Increased capillary permeability, protein shifts, inflammatory process, and evaporative losses greatly affect circulating volume and urinary output, especially during initial 2472 hr after burn injury. - Massive/rapid replacement with different types of fluids and fluctuations in rate of administration require close tabulation to prevent constituent imbalances or fluid overload. - May be helpful in estimating extent of edema/fluid shifts affecting circulating volume and urinary output.

Evaluation Within 30 minutes of nursing interventions the client was able to have moist mucous membranes; no thrist and a verbalization of Hindi n ako nauuhaw kagaya ng dati. And the goal was partially met.

- Maintain cumulative record of amount and types of fluid intake.

- Measure circumference of burned extremities as indicated.

Dependnet: - Administer calculated IV replacement of fluids, electrolytes, plasma, albumin as prescribed.

- Fluid resuscitation replaces lost fluids/electrolytes and helps prevent complications, e.g., shock, acute tubular necrosis (ATN). Replacement formulas vary (e.g., Brooke, Evans, Parkland) but are based on extent of injury, amount of urinary output, and weight. Note: Once initial fluid resuscitation has been accomplished, a steady rate of fluid administration is preferred to boluses, which may increase interstitial fluid shifts and cardiopulmonary congestion. - Allows for close observation of renal function and prevents urinary

Collaborative: -Assist in inserting indwelling urinary catheter.

retention. Retention of urine with its byproducts of tissue-cell destruction can lead to renal dysfunction and infection.