......... NCP Case
......... NCP Case
......... NCP Case
Nursing Diagnosis: Anxiety related to chronic illness w/ changes in roles/ body image.
Short-term Goal: At the end of my shift, patient will verbalize acceptance of self in situation.
Long-term Goal: At the end of hospitalization, patient will demonstrate adaptation to changes or events that have
occurred.
Cues: Problem Scientific Rationale Nursing Rationale Evaluation
Interventions
• Body ANXIETY Anxiety is a normal experience. • Assessed • Helps Goal met.
malaise Moderate or high level of anxiety level of determi Patient
can increase alertness and fear of ne the verbalized
• Blurred in client. kind of acceptance
performance in particular
vision interven of self in
situations. However, people who situation.
tions
experience continues or recurring required
• Restlessness • Explained
fears or episodes of intense fear procedure .
can feel powerless to manage their s/ care as • Fear of
symptoms and their lives can delivered. unknow
become severely restricted. Repeated n is
explanati lessene
on’s d by
frequently informat
http:/www.panicanxietydisorder.o as ion &
rg au /index.htm needed. may
enhanc
e
accepta
nce of
perman
ence of
ESRD
• Provided and
opportunit necessit
ies for y for
client to dialysis.
ask
questions • Creates
& feeling
verbalizati of
on of openne
concern. ss &
coopera
tion &
provides
informat
ion that
will
assist in
problem
identific
Name: Mrs. MM Age: 77 years old
Medical Diagnosis: ESRD secondary to DM Nephropathy
Nursing Diagnosis: Altered Fluids & electrolytes r/t Urinary retention as evidence increase K & decrease Na.
Short term Goal: At the end of my shift, patient will be able to increase urine output at least 1500cc in 24 hrs.
Long term Goal: At the end of hospitalization, the patient will be able to have a normal urine output & voiding pattern.
Cues Problem Scientific Nursing Intervention Rationale Evaluation
Rationale
• Monitor intake
• To determine
• Sodium- & output hourly
the progress of
134
• Percuss/palpate the disease
decreased
suprapubic
• A distended
(135-145 area.
mg/dl) bladder can be
felt in the
suprapubic
area.
• Observe Signs
and symptoms
of fluids & • To be able to
electrolytes prevent further
imbalance such complication
as dyspnea and administer
changes in proper
therapeutic
Name: Mrs. MM Age: 77 yrs. old
Short-term Goal: at the end of my shift, the clients will increase the sleeping hours from 5 hrs. to 8 hrs.
Long-term Goal: At the end of the patient’s hospitalization, patient achieves optimal amount of sleep as evidenced by
rested appearance, verbalization of having a good sleep and improvement in sleep pattern.
Scientific Nursing
Cues Problem Rationale Evaluation
Rationale Interventions
• To prevent
• Limit fluids
urinary
before
bladder
bedtime.
retention
causing
dribbling of
urine.
Nursing Diagnosis:Decreased tissue perfusion related to peripheral vasoconstriction as manifested by high blood
pressure.
Short – Term Goal:At the end of my shift, patient will decrease blood pressure from 160/90 to 130/90
Long - Term Goal: At the end of the patient’s hospitalization, will maintain adequate tissue perfusion as evidenced by BP
declining toward normal range for client.
Subjective: Decreased Constriction of • . Measure and recorded • Provides Goal not met.
Tissue the peripheral blood pressure as objective data Patient’s blood
No subjective Perfusion blood vessels for pressure
indicated
will alter the monitoring. remained
flow of blood to 160/90.
Objective: perfuse the
• Observed skin color, • Presence of
different cells of moisture, temperature, pallor: cool,
• Oliguria
the body. and capillary refill time. moist skin;
• Hyperten and delays
Reference: capillary refill
sive
time may be
www.elsevier.co
due to
• Restless m peripheral
ness vasoconstricti
on.
• Cold and • May
clammy indicate
skin heart or
renal
• Noted failure
dependent/general
edema
• Helps
reduce
sympatheti
c
stimulation
; promotes
relaxation.
• Reduces
• Provided calm, restful physical
surroundings, stress and
minimize tension
environmental that affect
activity/noise. Limit blood
the number of visitors pressure
and length of stay. and the
course of
• Maintain activity hypertensi
on.
restrictions; such as
• Decreases
bed rest/chair rest;
schedule periods of discomfort
uninterrupted rest; and may
assisted client with reduce
self-care activities as sympatheti
needed. c
stimulation
• Provided comfort
measure such back
massage, elevation of
head.
• Administered
antihypertensive • Antihypert
medications as ensive
prescribed medication
s play a
key role in
treatment
of
hypertensi
on
associated
with
chronic
renal
failure.
• Encouraged
compliance with • Adherence
dietary and fluid to diet and
restriction therapy. fluid
restrictions
and
dialysis
schedule
prevents
excess
fluid and
sodium
accumulati
on.
Nursing Diagnosis: Risk for systemic infection related to hemodialysis procedure as manifested by fatigue,
weakness and low Hb., Hct.level
Short term goal: At the end of the shift, patient will experience no signs/symptoms of infection.
Long – term goal: At the end of hospitalization, patient will maintain/demonstrate improvement in laboratory values
4.]Monitor BP
closely for
sudden drop
after drug is
stopped.
DRUG CLASSIFICATION MECHANISM OF INDICATION/ SIDE EFFECTS NURSING
NAME ACTION CONTRAINDICATION CONSIDERATIONS
4. ]Continue BP
control,
diet and exercise
for
disease control.
DRUG MECHANISM INDICATION/ NURSING
CLASSIFICATION SIDE EFFECTS
NAME OF ACTION CONTRAINDICATION CONSIDERATIONS
BRAND: Vitamins & Minerals Hematinic. Indications: Hypotension, chest 1. ]Watch for
Iron sucrose is pain, hypertension, serious
Encifer dissociated by Treatment of iron hypervolemia, CHF, hypersensitivity
the deficiency anemia in cramps, reactions of iron
reticuloendoth the following patients: musculoskeletal sucrose.
GENERIC: elial system Hemodialysis pain, diarrhea,
into iron and Dependent Chronic nausea, vomiting, 2. ]Medication is
Iron sucrose. Kidney Disease (HDD- abdominal pain, administered 1 to
sucrose Encifer iron CKD) patients receiving elevated liver 3
component an erythropoietin. enzymes, skin times/wk. Do not
appears to irritation, pruritis, administer more
distribute Contraindications: application site than
DOSAGE: mainly in the reaction, dizziness, 3 times/wk.
blood and to Patients with evidence dyspnea,
Amp 20 some extent in of iron overload, in pneumonia, cough, 3. ]For IV
mg/mL the patients with known headache, fever, administration
(brown, extravascular hypersensitivity to iron asthenia, malaise. only.
sterile, fluid. sucrose or any of its
aqueous inactive components .
soln) x 5's. and in patients with
anemia not caused by
iron deficiency.
DRUG MECHANISM INDICATION/ NURSING
CLASSIFICATION SIDE EFFECTS
NAME OF ACTION CONTRAINDICATION CONSIDERATIONS
BRAND: Hypnotics & Depresses the Indication: Amnesic 1]. Monitor blood
Sedatives limbic system episodes pressure, heart rate
Dormicum and reticular Disturbances of sleep and rhythm,
formation respiration, airway
(subcortical integrity,arterial
GENERIC: level of CNS) oxygen, saturation,.
by increasing Contraindication: Emergency
or facilitating equipment
Midazolam the inhibitory Hypersensitivity shoud be nearby.
neurotransmitt .
er activity of 2.] Its onset of action is
DOSAGE: GABA. 1
hour.The action
15mg ½ lasts for
tab OD 2-6 hours.
3. ]Dormicum is given
may
be slower in the
elderly
than in younger
adults.
1 tab OD
INDICATION/
DRUG CLASSIFICATIO MECHANISM NURSING
CONTRAINDICA SIDE EFFECTS
NAME N OF ACTION CONTRAINDICATIONS
TION
BRAND: anti angina Reduces Indications: Orthostatic 1.] Assess location,
cardiac oxygen hypotension, duration,
Minitran demand by Prophylaxis of tachycardia, intensity,and
decreasing left angina, palpitation, precipitating
ventricular end hypertension rash. factors of the patient’s
GENERIC: diastolic angina pain.
pressure (pre Contraindication
Nitroglyceri -load) and to s: 2.]Evaluate therapeutic
n patch lesser extent effectiveness (cardiac
systemic Severe anemia, status) and adverse
vascular increase response
resistance (after intracranial (hypotension,
DOSAGE: load). Also pressure, allergy arrhythmias)
increases blood to adhesives,
5 mg flow through the hypersensitivity to 3.]Dosed should be
OACW x collateral nitrates and reduced
16 h coronary orthostatic gradually when
vessels. hypotension. discontinuing after long-
term
therapy.
4.]Apply transdermal
(TD)
patches to area without
hair: press hard to
adhere if
patch becomes
dislodged,
apply a new one.
BRAND: Calcium Salt Essential for Indications: Venous irritation, 1.]If a precipitate is
maintaining tingling sensation, noted in the syringe do
Kalcinate normal Management of feeling of oppression not use.
function of hypocalcemia, or heat, chalky taste,
nerves, hypocalcemic tetany, fatigue, GI symptoms 2.]IV rate should not
GENERIC: muscles, the hyperkalemia with (anorexia, IV, nausea exceed 0.5-2 ml / min.
Calcium skeletal cardiac toxicity. and vomiting, 3.]Monitor calcium
Gluconate system, and abdominal pain, dry levels and renal
permeability mouth, thirst) function.
of cell Contraindications:
membranes
Digitalized clients,
and
DOSAGE: sarcoidosis, renal or
capillaries.
cardiac disease,
1amp SIVP ventricular fibrillation.
Cancer clients with
bone metastases,
renal calculi,
hypophosphatemia,
hypercalcemia
DRUG NAME