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Bio 2

Bio 2

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Published by Jennifer Pascual

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Categories:Topics, Art & Design
Published by: Jennifer Pascual on Sep 15, 2010
Copyright:Attribution Non-commercial

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09/23/2010

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AssessmentDiagnosisAnalysisGoals andObjectivesInterventionRationaleEvaluation
SUBJECTIVE :“Nahihilo poako, Nauuhawat nanlalata”as verbalizedby the client. [Means, I AMDIZZY, THIRSYAND I FEEL SOWEAK" ]OBJECTIVE :+ Sunken, Dryeyes+ Palepalpebralconjunctiva+ Dry lips andmouth+ProlongedCapillary refilltime [ 7seconds ]+ Poor skinturgor+ Rapid, Thready PulseFluid VolumeDeficit R/TIntravasculartoExtravascularPlasmaLeakageSecondary toIncrease inVascularPermeabilityDecreasedintravascular,interstitial,and/orintracellularfluid. Thisrefers todehydration,water lossalone withoutchange insodiumFluid volumedeficit, orhypovolemia,occurs from aloss of bodyfluid or theshift of fluidsinto the thirdspace, or froma reduced fluidintake.Commonsources forfluid loss arethegastrointestina
OBJECTIVES
SHORT TERM:After an hourof spontaneousfluidreplacement,Patient willgraduallyabate signsand symptomsof fluid volumedeficiency asevidenced byincreasingbloodpressure,decreasingheart rate,improvingcapillary refilltimepreferablybelow 5s andan improving1. Anticipatefluidreplacementby preparingperipheralroute for IVtransfusion.2. Obtaindoctor’s orderfor IV therapyAs soon aspossible toreplace fluidvolume lossIMMEDIATELY.3. Encouragefluid intake byplacing a glass1. IVtransfusion isa dependentnursingfunction.Anticipatedoctor’s orderby providingroute for IVfluidreplacementto save timeand decreaserisk forcomplications.2. IV isconsidered asMEDICATION.Beforeinitiating IVReplacementtherapy, makesure that thereis a currentstanding orverbal orderfrom thedoctor.SHORT TERM :After an hourof intervention,Patient’s BPincreased to100/70, Tachycardiaresolved asevidenced bya normal HR of 80bpm. CRTdecreasedfrom 7s downto 4s andthere is anoticeableimprovementin the client’sskin turgor.
{LONG TERM :2 Days after aseries of nursing care,the patient manifested anormal urineoutput of 30ml
X
 
Heart rate –110 BpmRR – 21 BpmBP – 90/60 Temp – 39.2 Cl (GI) tract,polyuria, andincreasedperspiration.Fluid volumedeficit may bean acute orchronicconditionmanaged inthe hospital,outpatientcenter, orhome setting. Thetherapeuticgoal is to treatthe underlyingdisorder andreturn theextracellularfluidcompartmentto normal. Treatmentconsists of restoring fluidvolume andcorrecting anyelectrolyteimbalances.Earlyskin turgor.
{ LONGTERM : After 2days of nursingintervention,Patient willmaintain fluid volume at anamount optimum for normalfunctioning asevidenced by a normal urineoutput withnormalspecificgravity, stablevital signs,moist mucusmembrane,good capillary refill time and resolution of third spacing.}
of juice orwater withinthe patient’sreach.4. Monitortotal fluidintake andoutput every 2hours.5. Watchtrends inoutput for 3days; includeall routes of intake andoutput andnote color andspecificgravity of urine.3. Placing aglass of wateror juice atpatient’sbedside is thebest way toencouragefluid intake.DHF patientare alwaysthirsty prior tothedefervescencestage.4. A urineoutput of .5 mlper kg/hr isinsufficient fornormal renalfunction andindicatesonset of renaldamage5. Monitoringfor trends for 2to 3 daysgives a morevalid picture of the client'shydration
 per hour witha specificgravity of 1.011. Stablevital signsweremonitored and recorded. CRT was recorded normal.Physicalassessment revealed nosign of fluid deficit.}
 
recognitionand treatmentare paramountto preventpotentially life-threateninghypovolemicshock.6. Monitor vitalsigns of clientswith deficientfluid volumeevery hour.Observe fordecreasedpulse pressurefirst, thenhypotension,tachycardia,decreasedpulse volume,and increasedor decreasedbodytemperaturestatus thanmonitoring fora shorterperiod. Dark-colored urinewithincreasingspecificgravity reflectsincreasedurineconcentration.6. To monitorand assessclient’sresponse andprogress in thefluidreplacementtherapy.

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