PATIENT INFORMATION

Name: B.E. NAME ALERT? Y N Age: 24 Date of Admission: July 18,2013 Chief Complaint : Fever, bipedal and periorbital edema Role: Family Support: SUBJECTIVE DATA
nahihirapan pa akong huminga paminsan minsan at ang bilis ng tibok ng puso ko ang bigat ng paa ko parang namamaga may manas nawawalan ako ng gana kumaen simula nung na confine ako 1itto

Gender: Male Diagnosis:

INTERVENTIONS NURSING DX/PROBLEM

Decreased cardiac output related to altered heart rhythm as manifested by increased cardiac rate

Monitor hemodynamic measurements Promote adequate rest Restrict fluid as indicated Assist in self care activities Weigh daily Evaluate laboratory datas Elevate edematous extremities Restrict sodium and fluid intake as indicated Record I/O accurately Change position frequently Place in semi fowlers Auscultate breath sounds Evaluate mentation Administer medications as prescribed Assist in developing individualized dietary regimen Provide dietary modifications Encourage client to choose foods that are appealing Minimize unpleasant odors Calculate basal energy expenditure

EXPECTED OUTCOME
After 8 hours of nursing intervention, the clients cardiac rhythm will normalize gradually

OBJECTIVE DATA
Easy fatigability Body weakness Periorbital edema Bipedal edema (grade 1) Decreased appetite Difficulty of breathing Chest pain Epigastric pain Weight gain Increased pulse rate

NURSING DX/PROBLEM
Fluid volume excess related to compromised regulatory mechanisms as manifested by bipedal edema and periorbital edema

EXPECTED OUTCOME
After 8 hours of nursing intervention the client will stabilize fluid volume as evidenced by I/O, Vital signs within clients normal limit

DIAGNOSTICS
Chest X-ray Abdominal Ultrasound Blood Culture CBC Clinical Chemistry ECG

TEACHING
Tell patient to be religious with the restriction of fluid intake Advise patient to have a choice of meal within the prescribed dietary regimen

NURSING DX/PROBLEM
Imbalanced nutrition less than body requirements related to therapeutic dietary restrictions as evidenced by lack of interest in food and observed inadequate intake

EXPECTED OUTCOME
After 8 hours of nursing intervention, the client will show interest in food and observe adequate intake.

Teach patient about the signs of fluid overload Tell patient to notify the nurse if signs of overload manifests Advise patient to have adequate rest periods Advise patient to take the medication regimen religiously

PHARMACOLOGY
Appebon Paracetamol (Biogesic) Paracetamol (Aeknil) Sevelamer (Renvela) Calcium Carbonate Essential Amino Acids (ketosteril) Metoclipramide (Plasil) Eperisone HCL (Myonal) Omeprazole (Prisolec) Cefuroxime (Ceftin Zinafec) Epoetin (Epogen) Amplodipine (Norvasc) Metoprolol (Lopressor) Tramadol

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