Nursing Diagnosis Outcome Nursing Intervention Evaluation

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Nursing diagnosis Outcome Nursing intervention Evaluation
Electrolyte Imbalanced related to excessive fluid loss as evidenced by BUSE result showed low Sodium 102 (Normal 135-145mmo/L) and patient vomiting 2 times in ETD. Patient will maintain electrolyte levels within normal limits or showed improvement in Sodium result during hospitalisation. 1. Assess patient for any physical signs of electrolyte imbalance such as cardiac, neurologic, and musculoskeletal symptoms so that early nursing intervention can be done to patient
2. Obtain the BUSE sample and evaluate the results to allow for prompt diagnosis and treatment of any abnormalities.
3. Administer intravenous fluids as ordered to promote the correction of low sodium
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1. Help client to perform active or passive ROM exercises to all extremities every 2 to 4 hours to foster muscle strength and tone, and maintain the joint mobility
2. Turn and reposition patient at least every 2 hours to prevent skin breakdown.
3. Teach family member of the client to maintain proper body alignment at all times to maintain optimal musculoskeletal balance and physiologic function.
4. Help patient perform self-care activities, assist during patient turning and sitting in his bed and meal time. Begin slowly and increase daily, as tolerated to regain independence and enhances self-esteem of the client.
5. Teach family member to assist patient with self-care activities to enable them to participate in patient’s care and encourages them to support patient’s independence.
6. Provide emotional support and encouragement to improve patient’s self-concept and motivate patient to perform ADLs.
7. Document the position in the Positioning chart as evidenced of nursing care had be done.
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Assess the skin all over the body especially at the bony prominence area as baseline data.
2. Monitor skin condition at least once a day for any signs and symptoms of skin breakdown such as redness of skin for early detection of skin problem and early actions can be taken.
3. Reposition the patient 2 hourly to reduce pressure on bony prominence areas.
4. Change all the wet or dirty linen immediately to prevent softening of skin and cause skin breakdown.
5. Keep the bed linen wrinkled-free and free from particles to prevent skin irritation and eventually skin breakdown.
6. Keep the head of bed at not more than 30 degree as tolerated by patient to prevent sliding down of patient in which can cause pressure over the buttock area, causing skin breakdown.

(Ralph & Taylor, 2014 ) 19/12/2014
@ 1.30 pm.
Patient’s skin maintains intact with no signs of skin breakdown.

• Encourage patient to increase the intake of oral sodium chloride in meal to improve the serum sodium

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