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5 C PR= 78 bpm RR= 21 breaths/min BP= 100/70 mmHg > appears weak > pale and dry conjunctiva and mucous membranes > poor skin turgor > capillary refill of 3s > decreased urine output from 40 cc/hr to 20 cc/hr > blood in stool > Hb= 5.6g/dl > Hct= 16.7% A:> Deficient Isotonic Fluid Volume related to active fluid volume loss Explanation of the Problem Chronic alcoholism NURSING CARE PLAN Objectives Nursing Interventions Dx:> Monitor v/s and record. Rationale
Date of Admission: April 17, 2009 Ward: Medical Ward 1
Evaluation > Goal met as evidenced by urine output of 30 cc/hr, stable v/s, warm skin, capillary refill of 2s, normal mentation or orientation to people and surroundings.
STO :> Within 8 hours of nursing intervention, the Pt. Formation of fibrous tissues will be free from signs of and nodules in the liver hypovolemic shock as evidenced by: Disruption of blood flow a.) urine output of at least 30 cc/hr Increased portal blood b.) stable v/s pressure c.) warm skin d.) capillary refill of 2s Dilatation of venous e.) normal mentation or channels behind the orientation to obstruction (between portal people and and coronary veins) surroundings Reversal of blood flow LTO :> Within 3 days of nursing intervention, the Pt. will have no signs of GI or any secondary bleeding as evidenced by: a.) absence of blood in Continuous increased portal stool or stool of blood pressure yellowish to brownish color Varices rupture b.) Hb level of 12-18 g/dl c.) Hct level of 36-55% Bleeding episodes = melena and hematemesis Formation of thin-walled varicosities in the submucosa of the esophagus Decreased circulating blood volume
> Provides baseline data for comparison. Changes in blood pressure and pulse rate may be used for rough estimate of blood loss. > Provides baseline data. Helps in determining location and onset of bleeding (eg. Bright red blood= acute arterial bleeding, possibly by gastric ulceration; Dark red blood= old blood retained in the intestines or venous bleeding from varices; Maroon-colored= rapid upper GI bleed). > Symptomatology is useful in gauging severity/length of bleeding episode. Worsening of symptoms may reflect continued bleeding, inadequate fluid replacement, and or shock. > Aids in establishing blood replacement needs and monitoring effectiveness of therapy.
> Note color and characteristics of stools.
>Note individualized physiologic response to bleeding such as changes in mentation, tachypnea, diaphoresis, pallor, etc.
> Goal met as evidenced by absence of blood in stool or stool of yellowish to brownish color, Hb level of 12 g/dl, and Hct level of 36%.
> Monitor laboratory studies including Hb, Hct, RBC count, BUN, and Cr levels.
Deficient Isotonic Fluid Volume
BUN greater than 40 with normal Creatinine level indicates major bleeding; BUN should return to client’s normal level approx. 12 hours after bleeding has ceased. >Monitor intake and output (I&O) > Note signs of renewed bleeding after cessation of initial bleed. >Provides guidelines for fluid replacement. > Increased abdominal fullness/distention, nausea or renewed vomiting, and bloody diarrhea may indicate rebleeding. > Lots of/ inadequate replacement of clotting factors may precipitate development of DIC.
> Observe for secondary bleeding; e.g., nose/gums, oozing from puncture sites, appearance of ecchymotic areas following minimal trauma. Tx:> Establish NPI.
> Facilitates participation of both the Pt. and SOs in the management of the condition. > Activity, vomiting, straining, and pain perception increases intraabdominal pressure and can predispose to further bleeding. >More easily digested and reduce risk of added irritation to inflamed
> Maintain bed rest; prevent vomiting and straining at stool. Schedule activities to provide undisturbed rest periods. Eliminate noxious stimuli. > Provide clear/bland fluids.
tissues. > Regulate IVF to prescribed rate, as ordered. > Facilitates adequate fluidelectrolyte replacement and balance; Support circulating blood volume to hasten healing process. > Packed red blood cells (PRCs) are adequate for stable clients with subacute/ chronic bleeding to increase oxygen-carrying capability; Supports circulating blood volume. > Inhibits gastric acid secretion and provides a protective coating to the mucosa. > Promotes hepatic synthesis of coagulation factors to support clotting. > Facilitates continuous monitoring of condition and cooperation of client. > Supports adequate nutrition and hydration; ensures continuity of care. > Caffeine and carbonated beverages stimulate hydrochloric acid (HCl) production, possibly potentiating rebleeding.
> Transfuse Packed RBC’s and regulate, as ordered.
> Administer proton pump inhibitor (Omeprazole), as ordered. > Administer Vitamin K, as ordered.
Edx:> Encourage to verbalize any untoward feelings or observations. > Encourage to continue gradual increase in food and fluid intake. > Advise to avoid caffeinated and carbonated beverages.
Patient Y Male 46 y/o Pleural Effusion Nursing Assessment O:> v/s taken as follows: T= 36.5 C PR= 73 bpm RR= 27 breaths/min BP= 90/70 mmHg > S/P CTT insertion > with CTT connected to a one-way water-sealed bottle > with dry and intact dressing on insertion site A:> Risk for infection r/t tissue trauma Explanation of the Problem Fluid accumulation in the lungs Pleural Effusion CTT insertion Tissue trauma on R midaxillary area May provide portal of entry for pathogens through: > unnecessary exposure of insertion and surgical site > inadequate aseptic techniques especially in wound dressing and watersealed bottle drainage > contact with Pt.’s, SOs’, and visitors’ hands or other body parts > delayed water-sealed bottle drainage May result to infection NURSING CARE PLAN Objectives Nursing Interventions STO:> Within 8 hours of nursing intervention, the Pt. and SOs will verbalize and demonstrate ways in preventing infection/ contamination, specifically proper handwashing, proper wound care, and water-sealed bottle drainage. LTO:> Within 3 days of nursing intervention, the Pt. will be free from any signs of infections as manifested by stable v/s and good skin integrity, characterized by absence of swelling, redness and pain on operative/insertion site. Dx:> Monitor v/s and record. Rationale
Date of Admission: April 20, 2009 Ward: Medical Ward 1
Evaluation > Goal met as evidenced by verbalization and demonstration of ways in preventing infection/ contamination, specifically proper handwashing, proper wound care, and watersealed bottle drainage.
> To provide baseline data for comparison. > Elevation in rates may signal infection. > To provide baseline data for comparison. > To check for skin integrity and identify need for further management. > Any obstructions and kinks may delay flow. Absence of fluctuations and excessive bubbling may indicate leaks. > Provides baseline data; purulent or sanguineous drainage, or increased amounts of drainage may signal worsening condition. > To promote fluidelectrolyte replacement and balance, and support circulating blood volume (for healing). > To prevent growth of MOs on dressings.
> Assess operative/insertion site for signs of infection.
> Assess patency and intactness of water-sealed bottle.
> Monitor and record amount and characteristics of drainage.
> Goal met as evidenced by absence of signs of infection as manifested by stable v/s and good skin integrity, characterized by absence of swelling, redness and pain on operative/insertion site.
Tx:> Regulate IVF to desired rate.
> Provide regular wound dressing.
> Change linens and Pt’s robes, as necessary.
> To promote comfort and hygiene. > To prevent growth of MOs on linens and robes. > To promote comfort and hygiene. > To prevent growth of MOs on tube. > To promote comfort and hygiene. > To prevent growth of MOs in water-sealed bottle. > To promote continuous drainage and prevent MO growth. > Inhibits bacterial wall synthesis making the pathogen vulnerable to changing osmotic pressures, thereby rendering the microorganism weak until it dies. > To promote NPI. > To allow continuous monitoring and assessment of Pt. condition. > To prevent contamination of operative/insertion sites. > To maintain intactness of
> Provide regular tube care.
> Provide bedside/ personal care. > Drain water-sealed bottle aseptically at intervals.
> Administer antibiotics (Cefuroxime), as ordered.
Edx:> Encourage Pt. to verbalize any untoward feelings, esp. discomfort or pain on operative/insertion site. > Instruct Pt. and SOs to refrain from touching/scratching operative/insertion sites.
dressings and CTT. > Instruct Pt and SOs to immediately report when dressings are soaked or when water-sealed bottle is almost full. > Demonstrate to Pt. and SOs the proper way of giving wound care and assisting with draining the water-sealed bottle, with emphasis on proper handwashing. > For immediate replacement and drainage to prevent contamination.
> To facilitate cooperation of Pt. and SOs in Pt. management. > To broaden the Pt.’s and SOs’ knowledge on such interventions. > To promote continuity of care. > To emphasize importance of aseptic techniques in preventing infection/contamination. > To prevent occurrence of superinfections.
> Inform Pt. and SOs of the importance of following the prescribed drug regimen.
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