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PATIENT NURSING CARE PLAN - eccdl.dcccd.edu

NAME: _____ PRIORITY # 3 PATIENT NAME: NURSING care plan NURSING Diagnosis Definition: The state in which an individual who is not NPO experiences or is at risk of experiencing vascular, interstitial or intracellular dehydration. DATA NURSING DIAGNOSIS NURSING Diagnostic Label Risk for fluid volume deficit MEASURABLE EXPECTED PATIENT OUTCOMEThe PATIENT will: Not develop a fluid volume deficit NURSING INTERVENTION Assess number of pads used and fluid loss every shift NURSING INTERVENTIONA ssess vital signs Q4H NURSING INTERVENTIONA ssess skin temp, turgor and color, mucous membranes every shift SUBJECTIVE: PATIENT reports leakage of light pink fluid.

NURSING CARE PLAN . Nursing Diagnosis Definition: The state in which an individual who is not NPO experiences or is at risk of experiencing vascular, interstitial or intracellular dehydration. DATA . NURSING DIAGNOSIS . Nursing Diagnostic Label . Risk for fluid volume deficit . MEASURABLE

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Transcription of PATIENT NURSING CARE PLAN - eccdl.dcccd.edu

1 NAME: _____ PRIORITY # 3 PATIENT NAME: NURSING care plan NURSING Diagnosis Definition: The state in which an individual who is not NPO experiences or is at risk of experiencing vascular, interstitial or intracellular dehydration. DATA NURSING DIAGNOSIS NURSING Diagnostic Label Risk for fluid volume deficit MEASURABLE EXPECTED PATIENT OUTCOMEThe PATIENT will: Not develop a fluid volume deficit NURSING INTERVENTION Assess number of pads used and fluid loss every shift NURSING INTERVENTIONA ssess vital signs Q4H NURSING INTERVENTIONA ssess skin temp, turgor and color, mucous membranes every shift SUBJECTIVE: PATIENT reports leakage of light pink fluid.

2 OBJECTIVE: PATIENT s pad shows leakage of blood and fluid. Ferrous sulfate 105 mg. po every day Weight 128 lbs. Height 4ft. 11 in. RBC (low) HGB (low) HCT (low) RELATED FACTOR (etiology) Bleeding Secondary to placenta previa AEB (for actual diagnosis) PATIENT s progress toward achievement of the outcome as evidenced by: STG: Vital signs WNL, skin warm and usual color, alert and oriented X3, urine output at least 30 cc s/hr, moist mucous membranes, cap refill <3 sec. On my shift LTG: The fetus will show no signs of distress R/T fluid volume deficit, FHT 120-160, Kickcount >3/hr Evaluation of effectiveness of the NURSING intervention Effective and why PATIENT change pad 2x and pad measured Not effective and why Unable to carry out and why Evaluation of effectiveness of the NURSING intervention Effective and why Vital signs WNL Not effective and why Unable to carry out and why Evaluation of effectiveness of the NURSING intervention Effective and why Skin warm, dry and pink.

3 Moist mucous membranes Not effective and why Unable to carry out and why Rationale for choice as priority NURSING Both mother and baby are at risk for complication of fluid loss with a diagnosis of placenta previa. Scientific Rationale To determine actual fluid loss Scientific Rationale Falling B/P and Increasing heart rate may indicate hypovolemia Scientific Rationale Early indicators of fluid volume deficit EVALUATION/CONCLUSION Continue plan Modify plan State rationale for plan continuation or modification All interventions working at maintaining fluid volume.

4 Continue plan until postpartum 55 NURSING INTERVENTION Assess mental status every shift NURSING INTERVENTION Strict I & O NURSING INTERVENTIONW eight PATIENT daily NURSING INTERVENTIONM onitor lab values and report decreasing values NURSING INTERVENTION Give Ferrous Sulfate 105 mg. daily NURSING INTERVENTION Increase fluid intake 2000/3000 liters per day Evaluation of effectiveness of the NURSING intervention Effective and why Alert and oriented X 3 Not effective and why Unable to carry out and why Evaluation of effectiveness of the NURSING intervention Effective and why Urine output 125 cc/hr Not effective and why Unable to carry out and why Evaluation of effectiveness of the NURSING intervention Effective and why weight WNL for pregnancy Not effective and why Unable to carry out and

5 Why Evaluation of effectiveness of the NURSING intervention Effective and why All low but WNL Not effective and why Unable to carry out and why Evaluation of effectiveness of the NURSING intervention Effective and why Gave medication Not effective and why Unable to carry out and why Evaluation of effectiveness of the NURSING intervention Effective and why PATIENT increased fluid intake by 500 cc s during my shift Not effective and why Unable to carry out and why Scientific Rationale Early indicator of fluid volume deficit Scientific Rationale Urine output > 30 cc/hr may indicate shock Scientific Rationale To determine fluid loss Scientific Rationale Will determine amount of blood loss Scientific Rationale Essential mineral found in HGB Scientific Rationale To replace fluid loss 56 57 NURSING INTERVENTION FHT every 4 hours NURSING INTERVENTION Kick count NURSING INTERVENTIONNURSING INTERVENTION NURSING INTERVENTION NURSING INTERVENTION Evaluation of effectiveness of the NURSING intervention Effective and why FHT 130 s every 4 hours Not

6 Effective and why Unable to carry out and why Evaluation of effectiveness of the NURSING intervention Effective and why Kickcount 8-10/hr Not effective and why Unable to carry out and why Evaluation of effectiveness of the NURSING intervention Effective and why Not effective and why Unable to carry out and why Evaluation of effectiveness of the NURSING intervention Effective and why Not effective and why Unable to carry out and why Evaluation of effectiveness of the NURSING intervention Effective and why Not effective and why Unable to carry out and why Evaluation of effectiveness of the NURSING intervention Effective and why Not effective and why Unable to carry out and why Scientific Rationale Decreased FHT may indicate decreased placental perfusion caused by hypovolemia Scientific Rationale Decreased kickcount may indicate decreased placental perfusion caused by hypovolemia Scientific Rationale Scientific Rationale Scientific Rationale Scientific Rationale

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