INEFFECTIVE HEALTH MAINTENANCE
ASSESSMENT/
CUES
Subjective
“Nakaka 10 hanggang
15 akong sigarilyo
araw-araw,” as
verbalized by the
patient.
Objective
 Report of unhealthy
practice
 With DM II
NURSING
DIAGNOSIS
Ineffective health
maintenance
related to lack of
interest in
improving health
behavior as
evidenced by
verbal report.
BACKGROUND
KNOWLEDGE
Inability to
identify, manage,
or seek out help
to maintain
health.
.
GOAL/
OBJECTIVES
Long Term:
To identify and
accept positive
and
negative
expressions,
feelings,
and
reactions.
Short term:
At the end of the
shift, the patient
will
verbalize
acceptance
of
adopting lifestyle
changes.
NURSING
INTERVENTIONS
RATIONALE
EVALUATION
a. Assessed for factors a. To
assess
the
Goal met.
that that result in
causative
or
alterations in health.
contributing factor Patient was able to
verbalize
b. Explored health b. Determines
the acceptance
in
promotion
behaviors
beginning point for altering his present
that patient is willing to
planning
and lifestyle.
incorporate
into
interventions
to
lifestyle.
assist patient in Also, patient’s SO
addressing needs.
showed willingness
to help carry out
c. Monitored and
c. To
serve
as plan in order for
recorded V/S.
baseline data.
the patient’s bad
habit be removed.
d. Rendered health
d. Knowing
the
teaching:
effects of tobacco
 effects of
to health will help
tobacco in the
in altering present
body
health
practice.
 food intake
Also, proper food
 exercise
intake and exercise
are important in
maintaining health.
e. Involved patient’s SO
in developing plan to
alter client’s negative
behavior.
e.
This
promotes
cooperation in meeting
goal of care.
Name of Drug
Generic name:
Mannitol
Brand name:
Classification:
Osmotic diuretic
Dosage:
75 cc
Form:
IV solution
Frequency:
q8
Route:
IV
Mechanism of Action
Indication
Contraindication
Adverse Effects
Mannitol elevates
blood
plasma
osmolality, resulting in
enhanced flow of
water from tissues,
including the brain and
cerebrospinal
fluid,
into interstitial fluid
and plasma. As a
result, cerebral edema,
elevated intracranial
pressure,
and
cerebrospinal
fluid
volume and pressure
may be reduced
Reduction
of
intracranial pressure
and brain mass;
Cerebral edema
 Pulmonary
congestion
or
edema
 CHF
 Metabolic edema
with
abnormal
capillary fragility
 Anuria due to
severe
renal
disease
 Severe
dehydration
 Fluid
and
electrolyte
imbalance;
 Acidosis
(with
high doses)
 Nausea
and
vomiting
 Headache,
dizziness, chills,
fever
 Tachycardia, chest
pain
 Blurred vision;
 Hypotension
or
hypertension;
 Acute renal failure;
 Skin necrosis;
 Thrombophlebitis.
Nursing Responsibilities
1. Note reason for therapy,
characteristic
S&S,
underlying cause.
2. List
other
medications
prescribed to ensure none
alter drug effects.
3. Document
findings,
circulatory
functions.
neurologic
evaluate
and
renal
4. Asses for S&S of fluid and
electrolyte imbalances.
5. Monitor V/S and IO.
6. Report
any
S&S
of
pulmonary
edema
manifested by dyspnea,
cyanosis,
rales,
and/or
frothy sputum.