NURSING CARE PLAN
Name of Patient:
Chronic renal failure secondary to DM nephropathy.
: Risk for ineffective protection related to abnormal blood profile.FindingsExpected OutcomeNursing Interventions and RationaleActual Evaluation
O= Received patient on bed,awake, conscious withintravenous fluid of # 1 D50.3% NaCl 500cc @ KVO,infusing well at left arm.> With ventriculostomy tubefreely draining to blood bag;dressing is dry and intact.> With traeostomy attachedto mechanical ventilator,with FIO2 of 80%.> With nasogastric tube for feeding.WBC= 20TRBC= 3.5 million/uL> With the following vitalsigns of:>T=36.5
C.>P=100bpm.>R= 22 cpm.>BP=130/80mmhgWithin 8 hours of nursingintervention, the patient will be able to:1. Experience no signs/symptoms of bleeding.2. Maintain / demonstrateimprovement in laboratoryvalues.-Hand washing and observe proper medical asepsis and limit visitors.R= to limit transmission of infections since the patient has a weak immune system.-Note reports of increasing fatigue, weakness. Observe for tachycardia, pallor of skin/ mucous membranes, dyspnea , and chest pain. Plan patientactivities to avoid fatigue.R=May reflect effects of anemia and cardiac response. To let the patientrest.-Note for the sign of infections in the operative site and change thedressing regularly.R= since the patient undergone ventriculostomy, noting and changing thedressing can help minimize the infection.After 7-8 hours of nursingintervention, the patient was:1. Still in coma, no signs of increased ICP noted.2. Displayed no further deterioration.3. With stable vital signs of >T=36.8
C.>P= 101 bpm.>R= 21 cpm.>BP=140/80mmhg Noted By:Senior/ Staff Nurse & Nurse Supervisor