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Objective: -increased RR : 34 -shortness of breath -facial grimace -altered body position -pale looking
Diagnosis Ineffective breathing pattern r/t hypoventilation as manifested by increased RR, shortness of breath, facial grimace, altered body position
Planning After 1hr. of Nsg. Intervention, the client will be able to verbalize awareness of causative factors.
Intervention Auscultate chest, noting presence/ character of breath sounds, presence of secretion
Evaluation After 1hr. of Nsg. Intervention, the client able to verbalized awareness of causative factors.
note rate and depth of respiration, type of breathing pattern. Administer oxygen at lowest concentration indicated for underlying pulmonary condition, respiratory distress or cyanosis encourage position of comfort
Assessment
Subjective: lumalaki ang tyan ko as verbalized by the patient. Objective: -pallor -jaundice -weak in appearance -Abdominal distention noted -irritability noted -Edema -DOB with RR of 34 bpm -abdominal girth of 42
Planning Fluid volume excess After 6hrs. of r/t to compromised nursing regulatory interventions. mechanism Patient will secondary to cirrhosis demonstrate of the liver as stabilized fluid manifested by pallor, volume and jaundice, weak in decrease edema appearance, abdominal distention, and abdominal girth. irritability, Edema,
DOB with RR of 34 and abdominal girth of 42
Diagnosis
-Monitor BP
Evaluation After 6hrs. of nursing interventions. The patient demonstrated stabilized fluid volume and decreased edema and abdominal girth.
Used with caution to control edema and ascites, block effect of aldosterone, andincrease water excretion while sparing potassium.