I. Introducción
6. Elevar los niveles de producción, productividad y competitividad del sector forestal
7.2 Suelos forestales
DATE ACTIVE PROBLEM NURSING INTERVENTIONS EVALUATION
April 22, 2010 Impaired gas exchange related to alveolar edema due to elevated ventricular pressures
Subjective cue:
“Maglisod jud ko'g ginhawa”,as verbalized by the patient
Objective cue:
>restlessness
>irritability
>diaphoresis
>bilateral crackles that do not clear with cough
>pale skin color Scientific Analysis:
Dyspnea, or shortness of breath, may be precipitated by minimal to moderate activity (dyspnea on exertion [DOE]);
dyspnea also can occur at rest.
The patient may report
orthopnea, difficulty in breathing when lying flat. Patients with
Independent:
1. R: Monitor vital signs and cardiac rhythm
I: for baseline data and monitoring 2. R: Auscultate breath sounds, I: notes areas of
decreased/adventitious breath sounds
3. R:Note character and
effectiveness of cough mechanism I: ability to clear airways of
secretions
4. R: Elevate head of bed, provide adjuncts and suction, as indicated I: to maintain airway
5. R: Encourage frequent position changes and
deep-breathing/coughing exercises. Use incentive spirometer, chest
physiotherapy, as indicated I: promotes chest expansion and drainage of secretions
6. R: Maintain adequate I/O I: for mobilization of secretions 7. R: Encourage adequate rest and
Desired Outcome:
After 8 hours of nursing intervention, the patient was able to demonstrate improved ventilation and adequate
oxygenation of tissues by ABGs within patient's normal limits and absence of symptoms of respiratory distress
Actual Outcome:
After 8 hours of nursing intervention, the objectives were partially met. The patient was able to improved
ventilation and
oxygenation of tissues as
evidenced by patient breathing without using much of the accessory muscle
orthopnea usually prefer not to lie flat. They may need pillows to prop themselves up in bed, or they may sit in a chair and even sleep sitting up. Some patients have sudden attacks of
orthopnea at night, a condition known as paroxysmal nocturnal dyspnea (PND).
The cough associated with left ventricular failure is initially dry and nonproductive. Most often, patients complain of a dry hacking cough that may be mislabeled as asthma or chronic obstructive pulmonary disease (COPD). The cough may become moist. Large quantities of frothy sputum, which is sometimes pink (blood tinged), may be produced, usually indicating severe
pulmonary congestion (pulmonary edema).
Adventitious breath sounds may be heard in various lobes of the lungs. Usually, bi-basilar crackles that do not clear with coughing are detected in the early phase of left ventricular
limit activities to within client tolerance.
I: Promote calm/restful environment helps limit oxygen need/consumption 8. R: Keep environment
allergen/pollutant free
I: to reduce irritant effect of dust and chemicals on airway
9. R: Provide psychological support, active-listen questions/concerns I: to reduce anxiety
Dependent:
1. R: Administer medications, as indicated
I: to treat underlying conditions Source: Source: Sparks, S and Taylor, C, Nursing Diagnosis Reference Manual 3rd edition;
Springhouse Corporation, Pennsylvannia
failure. As the failure worsens and pulmonary congestion increases, crackles may be auscultated throughout all lung fields. At this point, a decrease in oxygen saturation may occur
(Wolkenstein, 2000).
April 22, 2010 Decreased Cardiac Output related to impaired contractility and increased preload and afterload.
Subjective cue:
“Sige ra jud kog pangluspad”,as verbalized by the patient pulmonary pressures that cause decreased oxygenation, the
amount of blood ejected from the left ventricle may decrease,
Independent:
1. R: Place patient at physical and emotional rest
I: to reduce work of heart.
2. R: Provide rest in semi-recumbent position or in armchair in
air-conditioned environment I: that reduces work of heart,
increases heart reserve, reduces BP, decreases work of respiratory
muscles and oxygen utilization, improves efficiency of heart
contraction; recumbency promotes diuresis by improving renal perfusion 3. R:Provide bedside commode I: to reduce work of getting to bathroom and for defecation.
4. R: Provide for psychological rest since emotional stress produces vasoconstriction.
I:elevates arterial pressure, and
Desired Outcome:
After 8 hours of nursing intervention, the patient was able to demonstrate improved cardiac output within normal levels of preload and afterload.
Actual Outcome:
After 8 hours of nursing intervention, the objectives were partially met. The patient was able to initiate actions to increase cardiac output but symptoms persisted.
sometimes called forward failure.
The dominant feature in HF is inadequate tissue perfusion. The diminished CO has widespread manifestations because not enough blood reaches all the tissues and organs (low perfusion) to provide the
necessary oxygen. The decrease in SV can also lead to stimulation of the sympathetic nervous
system, which further impedes perfusion to many organs.
Blood flow to the kidneys decreases, causing decreased perfusion and reduced urine output (oliguria). Renal perfusion pressure falls, which results in the release of renin from the kidney. Release of renin leads to aldosterone secretion.
Aldosterone secretion causes sodium and fluid retention, which further increases intravascular volume. However, when the patient is sleeping, the cardiac workload is decreased, improving renal perfusion, which then leads to frequent urination at night (nocturia).
Decreased CO causes other
speeds the heart.
5. R: Promote physical comfort. Avoid situations that tend to promote
anxiety and agitation. Offer careful explanations and answers to the patient's questions.
I: Decreases anxiety
6. R: Take frequent BP readings.
Observe for lowering of systolic pressure. Note narrowing of pulse pressure. Note alternating strong and weak pulsations (pulsus alternans).
Auscultate heart sounds frequently and monitor cardiac rhythm. Note presence of S3 or S4 gallop (S3 gallop is a significant indicator of heart failure). Monitor for premature ventricular beats.
I: Evaluates for progression of left-sided heart failure.
Source: Source: Sparks, S and Taylor, C, Nursing Diagnosis Reference Manual 3rd edition;
Springhouse Corporation, Pennsylvannia
symptoms. Decreased
gastrointestinal perfusion causes altered digestion. Decreased brain perfusion causes dizziness, lightheadedness, confusion, restlessness, and anxiety due to decreased oxygenation and blood flow. As anxiety increases, so does dyspnea, enhancing anxiety and creating a vicious cycle.
Stimulation of the sympathetic system also causes the
peripheral blood vessels to constrict, so the skin appears pale or ashen and feels cool and clammy.(Wolkenstein, 2000).
April 22, 2010 Excess fluid volume related to excess fluid or NA intake and retention of fluid secondary to Heart failure and its medical therapy
Subjective cue:
“puno kaayo akong gibati,”, as verbalized by the patient
Objective cue:
>Adventitious breath
Independent:
1. R: Compare current weight
admission and/or previously stated weight
I: provides a comparative baseline 2. R: Auscultate breath sounds I: for presence of crackles and congestion
3. R: Measure abdominal girth for changes that
I: may indicate increasing fluid retention/edema
Desired Outcome:
After 8 hours of nursing intervention, the patient was able to stabilize fluid volume as evidenced by balance I/O, vital signs within patient's normal limits, stable weight, and free signs of edema
Actual Outcome:
After 8 hours of nursing intervention, the objectives
sounds(crackles)
Fluid that accumulated in the dependent extremities during the day begins to be reabsorbed into the circulating blood volume when the person lies down.
Because the impaired left ventricle cannot eject the increased circulating blood volume, the pressure in the pulmonary circulation increases, causing further shifting of fluid into the alveoli. The fluid filled alveoli cannot exchange oxygen and carbon dioxide. Without sufficient oxygen, the patient experiences dyspnea and has difficulty getting an adequate amount of sleep. (Wolkenstein, 2000).
4. R: Assess neuromuscular reflexes I: to evaluate for presence of
electrolyte imbalances such as hypernatremia
5. R: Observe skin and mucous membranes
I: for presence of decubitus/ulceration
6. R: Elevate edematous extremities, change position frequently
I: to reduce tissue pressure and risk for skin breakdown
7. R: Place in semi-Fowler's position, as appropriate
I: to facilitate movement of diaphragm, thus improving respiratory effort
Dependent:
1. R: Administer medications (e.g.diuretics)
I: To treat underlying conditions Collaborative:
1. R: Restrict sodium and fluid intake, as indicated
I: for nutritional therapy
Source: Source: Sparks, S and
were partially met. The patient was able to have a normal vital signs of
T-37.1 c, P-77 bpm
R-19 cpm, BP- 110/70 mmHG
Taylor, C, Nursing Diagnosis Reference Manual 3rd edition;
Springhouse Corporation, - limited range of motion
- short term performance of an required to meet all of the body’s needs. To compensate, blood is
Independent:
1. I: Discuss with the patient the need for activity.
R: Improves physical and psychosocial well-being.
2. I: Identify activities the patient considers desirable and meaningful.
R: To enhance their positive impact.
3. I: Encourage patient to help plan activity progression, being sure to include activities the patient
considers essential.
R: Participation in planning helps ensure patient compliance.
4. I: Instruct and help patient to alternative periods of rest and activity.
R: To reduce the body’s organ demand and prevent fatigue.
5. I: Identify and minimize factors that decrease the patient’s exercise tolerance.
R: To help increase the activity level.
6. I: Monitor physiological responses to increased activity.
Desired Outcomes:
After 8 hours of nursing interventions,
* Patient states desire to increase activity level.
* Patient states understanding of the need to increase activity level gradually.
* Blood pressure and pulse and respiratory rates remain within prescribed limits during
activity.
* Patient states satisfaction with each new level of activity attained.
* Patient demonstrates skill in conserving energy while
carrying out daily activities to tolerance level.
* Patient explains illness and connects symptoms of activity intolerance with deficit in oxygen supply or use.
Actual Outcome:
diverted away from less-crucial areas, including the arms and legs, to supply the heart and brain. As a result, people with heart failure often feel weak (especially in their arms and legs), tired and have difficulty performing ordinary activities such as walking, climbing stairs or carrying groceries
R: To ensure return to normal a few minutes after exercising.
7. I: Teach patient how to conserve energy while performing activities of daily living.
R: These measures reduce cellular metabolism and oxygen demand.
8. I: Teach patient exercises for increasing strength and endurance.
R: Improves breathing and gradually increase activity level.
9. I: Support and encourage activity to patient’s level of tolerance.
R: Helps patient develop level of tolerance.
10. I: Before discharge, formulate a plan with the patient and caregivers that will enable the patient either to continue functioning at maximum activity intolerance or to gradually increase the tolerance.
R: Participation in planning
encourages patient satisfaction and compliance.
Source: Source: Sparks, S and Taylor, C, Nursing Diagnosis Reference Manual 3rd edition;
Springhouse Corporation,
Afer 8 hours of nursing intervenions, the objectives were partially met. The:
*Patient stated understanding of the need to perform daily activities.
*Patient demonstrated
conservation of energy while performing activities.
Pennsylvannia April 23, 2010 Ineffective airway clearance
related to presence of
tracheobronchial obstruction Cues and Evidences:
Subjective:
“maglisod ko ug ginhawa nya huot ako dughan,” as verbalized by the patient.
Objective:
- shortness of breath - dyspnea
- use of accessory muscles when breathing
- tachypnea with RR of 28 Scientific Analysis:
Mucus is produced at all times by the membranes lining the air passages. When the membranes are irritated or inflamed, excess mucus is produced and it will retain in tracheobronchial tree.
The inflammation and increased in secretions block the airways making it difficult for the person
Independent:
1. I: Assess respiratory status at least every for hours or according to establishment standards.
R: To detect early signs of compromise.
2. I: Place patient in Fowler’s position and support upper extremities.
R: To aid breathing and chest expansion, and to ventilate basilar lung fields.
3. I: Help patient turn, cough, and deep breath every 2 to 4 hours.
R: To help prevent pooling of secretions and to maintain airway patency.
4. I: Suction as needed. Be alert for progression of airway clearance.
R: To stimulate cough and airways.
5. I: Encourage fluids (atleast 3,000 mL daily).
R: To ensure adequate hydration and loosen secretions, unless
contraindicated.
6. I: Mobilize patient to full capabilities.
R: To facilitate chest expansion and
Desired Outcome:
After 8 hours of nursing interventions,
* Patient clears airway using controlled coughing
techniques.
* Patient expectorates sputum.
* Patient drinks 3 to 4 liters of fluid daily.
*Patient’s arterial blood gas values are within normal limits.
*Patient performs chest
After 8 hours of nursing interventions, the objectives were partially met. The:
*Patient verbalized
understanding on coughing techniques
* Patient increased fluid
volume to 3 to 4 liters per day.
to maintain a patent airway. In order to expel excessive secretions, cough reflex will be stimulated. An increased in RR will also be expected as a compensatory mechanism of the body due to obstructed airways (Wolkenstein, 2000).
ventilation.
7. I: Perform postural drainage, percussion, and vibration every 4 hours or as ordered.
R: To enhance mobilization of of secretions that interferes with oxygenation.
8. I: Avoid supine position for
extended periods. Encourage lateral, sitting, prone, and upright positions as much as possible.
R: To enhance lung expansion and ventilation.
9. I: Provide tissues and paper bags for hygienic sputum disposal.
R: To prevent spreading infection.
10. I: Monitor and document sputum characteristics every shift.
R: To gauge therapy’s effectiveness.
Source: Sparks, S and Taylor, C, Nursing Diagnosis Reference Manual 3rd edition; Springhouse Corporation, Pennsylvannia
XI. Drug Study
750mg IVTT It is effective for the treatment of penicillinase-producing Neisseria gonorrhoea (PPNG).
Effectively treats bone and joint infections, bronchitis,
meningitis, gonorrhea, otitis media, pharyngitis/tonsillitis, sinusitis, lower respiratory tract infections, skin and soft tissue infections, urinary tract
infections, and is used for surgical prophylaxis, reducing
• Determine history of hypersensitivity reactions to cephalosporins, penicillins, and history of allergies, particularly to drugs, before therapy is initiated.
• Inspect IM and IV injection sites frequently for signs of phlebitis.
• Report onset of loose stools or diarrhea. Although pseudomembranous colitis.
• Monitor I&O rates and pattern: Especially important in severely ill patients receiving high doses. Report any significant changes.