NURSING CARE PLAN CUES Subjective cues: “Di man kami maaram kun paano iton niya nakuha nga sakit…”as verbalized by the patient’s grandmother. “Deri namon ini hiya iguin dadara ha clinic o hospital kay na itatambal man namon hiya, sugad han sipon ug ubo, iguin papatumar namon hiya hin Mucosolvan Tempra Paracetamol na iguin tutumar
NURSING DIAGNOSIS Deficient knowledge regarding condition, related to lack of exposure.
RATIONALE Health literacy is the ability to read, understand, and act on health information, including such tasks as comprehending prescription labels, interpreting appointment slips, completing, health insurance forms, and following instructions for diagnostic tests. Limited health literacy skills are often greater among certain groups: older adults, people with limited education, poor people, minority population, and people with
OBJECTIVES After 3-4 hours of nursing interventions, the family of the patient will be able to:
1. Participate in the learning process. 2. State at least least 3 factors that can cause PSGN: a. Modifiable 1. Diet 2. Sanitation b. Non-modifiable 1. Age 2. Environment 3. Economic Status
NURSING INTERVENTIONS 1. Establish rapport. a. Introduce self. b. Explain purpose.
To ensure compliance of the patient.
2. Select a variety of teaching strategies (e.g., pamphlets, visual aids, hand-outs)
Use of different means of accessing information promotes learner retention.
Assessment 1. Assess readiness readiness to learn and and individual learning needs: a. Ascertain level level of knowledge, knowledge, including anticipatory needs. b. Determine family’ family’s ability or readiness and barriers to learning.
c. Be alert alert to signs of avoidance.
3. Verbalize in his/her his/her own understanding the disease process. 4. Verbalize in his/her his/her own understanding of therapeutic needs. 5. Demonstrate,
RATIONALE
2. Assess the SO’s motivation: motivation: a. Identify motivating factors for the individuals.
EVALUATION After 3-4 hours of nursing interventions, interventions, the goals and objectives have been met and the family of the patient were able to:
1. Participate attentively in the learning process. 2. State 3 factors factors that can cause PSGN.
Individual may not be physically, emotionally, or mental capable at this time. SO may need to suffer consequences of lack of knowledge before he or she is ready to accept information. Motivation may be positive or negative.
3. Verbalize the nursing process on his own understanding. 4. Verbalize in his own understanding of therapeutic needs.
5. Demonstrate, properly
nakaka-usa kada adlaw hasta maupay an sakit.”As verbalized by the mother.
Objective cues: History of Past Illness:
Hospitalization and Surgeries . The patient has no history of either minor or major surgeries. No other hospitalization s done except for current admission of PSGN.
Educational level of the father: College undergradu ate Educational
limited English proficiency. Low health literacy skills are associated with poor health outcomes and higher health costs. For example, a client may not be able to read a prescription. Clients with low literacy skills have less information about health promotion and/or management of a disease process for themselves and their families because they are unable to read the educational materials. As a result, they have higher rates of hospitalization than people with adequate health
properly check and monitor the patient's blood pressure. 6. Enumerate at least 3 ways on how to prevent the recurrence of the disease. a. Proper hygiene b. Proper hand washing c. Diet modification d. Proper environmental sanitation 7. Initiate necessary lifestyle changes and participate in treatment regimen.
b. Provide information relevant only to the situation.
To prevent overload.
c. Provide positive reinforcement.
Can enforce continuation of efforts.
Health Teaching 1. Review disease process/ prognosis at family’s level of understanding. a. Etiology b. Risk Factors c. Disease Process
2. Instruct and demonstrate to
the family the correct technique for monitoring blood pressure.
6. Enumerate 3 ways on how to prevent the recurrence of the disease.
Provides knowledge base from which client cam make informed choice.
It is vital that blood pressure be controlled to prevent further renal damage.
3. Explain prescribed medications Adequate along with their rationale, understanding that dosage and expected or side effects are adverse side effects. common and often subside with time and can enhance cooperation with treatment plan.
a. Co-amoxiclav 457 mg/5mL, BID
check and monitor the patient’s blood pressure.
Antibiotic; Killing bacteria that cause
7. Initiate necessary lifestyle changes and participate in treatment regimen.
level of the mother: High school graduate Age of patient: 4 years old, pre-primary pupil
literacy.
infections. It contains two different medicines called amoxicillin and clavulanic acid. Amoxicillin belongs to a group of medicines called "penicillins" that can sometimes be stopped from working (made inactive). The other active component (clavulanic acid) stops this from happening. Adverse Effects: Hypersensitivity, dizziness, headache
Reference: Fundamentals of Nursing by Kozier & Erb 8 th Ed, page 496
b. Furosemide , 20mg 1 ½ tab, q6h
Loop diuretic; Inhibits the reabsorption of sodium and chloride from the ascending limb of the loop of Henle, proximal and distal renal tubule. Increases renal excretion of water, sodium, chloride, magnesium,
potassium, and calcium Adverse Effects: blurred vision, dizziness anorexia, constipation, diarrhea, dry mouth, excessive urination, dehydration, headache c. Captopril, 25 mg/tab ½ tab
ACE inhibitor; ACE inhibitors block the conversion of angiotensin I to the vasoconstrictor angiotensin II. ACE inhibitors also prevent the degradation of bradykinin and other vasodilatory prostaglandins. ACE inhibitors also increase plasma renin levels and reduce aldosterone levels. Net result is systemic vasodilation. Adverse Effects: Dizziness, Drowsiness,
Fatigue, Headache, Insomnia Cough, Dyspnea Hypotension, Chest Pain, Edema, Tachycardia Abdominal Pain, Anorexia, Constipation, Diarrhea, Nausea, Vomiting d. Benzyl PCN, 800,00 IU IVTT q6H
Bactericidal; The penicillins and penicillinaseresistant antibiotics produce bactericidal effects by interfering with the ability of susceptible bacteria to build their cell walls when they are dividing. These drugs prevent the bacteria from biosynthesizing the framework of the cell wall, and bacteria with weakened cell walls swell and then burst from osmotic pressure within the
cell. Because human cells do not use the biochemical process that bacteria use to form the cell wall, this effect is a selective toxicity. Adverse Effects: Hypersensitivity reactions including uticaria; fever; joint pains; rashes; convulsions; diarrhea; Anaphylaxis e. Dopamine side drip @ 6 gtts/min
Vasopressors; stimulate dopaminergic receptors, producing renal vasodilation. Adverse Effects: Headache, Dyspnea, Arrhythmias, Hypotension Nausea, Vomiting Irritation at IV Site
,
4. Encourage proper hygiene.
Edema interferes
with cellular nutrition, which makes the client more susceptible to skin breakdown; good hygiene is an intervention to prevent this complication. -Impetigo : Teach control of contagion: thorough hand washing, separate laundry for client’s linens, separate washing of client’s dishes, hand-washing before and after contact with patient.
5. Discuss dietary plan. - Low Protein, High Calorie Diet
- Low Salt Diet
Impetigo is contagious. Infection is present as long as skin lesions are present. Hand washing: To reduce the risk of crosscontamination among clients.
This diet is designed to avoid protein catabolism and enables the kidney to rest because it handles fewer protein molecules and metabolites. Sodium is
restricted, depending on the amount of edema noted. - TFR: 495 mL/day
6. Emphasize the importance of a clean and healthy environment.
Fluid intake is usually restricted. Nightingale believed that the environment was the major component creating illness in a patient; she regarded disease as “the reaction of kindly nature against the conditions in which we have placed ourselves.”
