XI.

Nursing Care plan Nursing Diagnosis Deficient fluid volume related to blood loss as evidenced by vaginal bleeding for 2weeks, decreased hemoglobin and hematocrit result. Rationale Predisposing factors (44 years old, female, gravida 4, genetic predisposition) ↓ Formation of tumor in the muscles of the uterus ↓ Presence of vaginal bleeding ↓ Blood loss ↓ Decreased hemoglobin and hematocrit result ↓ Deficient fluid volume Desired Outcome Nursing Intervention Justification Evaluation After 5 days of nursing intervention, client was able to: a. Goal met. Patient experiences adequate fluid volume and electrolyte balance as evidenced by urine output greater than 30 ml/hr, normal vital signs and normal skin turgor. b. Goal met. The patient was able to understand the importance of taking supplements especially iron and eating nutritious foods.

Assessment Data Actual and Abnormal findings: Subjective data: - clients says “Damo ang ga gwa sa akon nga dugo.” Objective data: - decreased hemoglobin and hematocrit count - profused menstruation risk factors: - multiparity - Advanced age - financial problems Wellness: - With family support. - Religious

After 2 days of INDEPENDENT nursing intervention, - Monitor active fluid loss client will be able from wound drainage, tubes, to: diarrhea, bleeding, and vomiting a. Experience adequate fluid - Monitor temperature volume and electrolyte balance. - Encourage patient to drink prescribed fluid amounts. - Monitor serum electrolytes and urine osmolality and report abnormal values. b. Will be COLLABORATIVE able to identify some - Assist the physician with management to insertion of a central venous maintain health. line and arterial line as indicated.

- Maintain accurate input and output.

- Febrile states decrease body fluids through perspiration and increased respiration. - Oral fluid replacement is indicated for mild fluid deficit. - Elevated hemoglobin and elevated blood urea nitrogen (BUN) suggest fluid deficit. Urine-specific gravity is likewise increased. - This allows more effective fluid administration and monitoring.

NANDA Definition: Decreased intravascular, interstitial, and/or intracellular fluid. This refers to dehydration, water loss alone without change in sodium

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Assessment Data Actual and Abnormal findings: Subjective data: - client verbalizes “indi ko kapangusog kay gasakit ang gin operahan sakon” Objective data: - Facial expression indicates slight discomfort. - Limited range of motion - Body weakness - Activity intolerance risk factors: financial problems

Nursing Diagnosis Risk for Infection related to exposure of surgical wound in the environment

Rationale Precipitating factor (Presence of surgical wound) ↓ Exposure of the surgical wound to harmful microorganisms. ↓ Natural defense mechanisms of the body are inadequate ↓ Unable to protect the body or unable to combat the invading organism adequately ↓ Increased opportunity for invading organism ↓ Risk for infection

Desired Outcome After 2 days of nursing intervention, client will be able to: a. Patient remains free of infection, as evidenced by normal vital signs and absence of purulent drainage from wounds, incisions, and tubes.

Nursing Intervention INDEPENDENT - Assess nutritional status, including weight, history of weight loss, and serum albumin.

Justification - Patients with poor nutritional status may be anergic, or unable to muster a cellular immune response to pathogens and are therefore more susceptible to infection. - This maintains optimal nutritional status. - Friction and running water effectively remove microorganisms from hands. Washing between procedures reduces the risk of transmitting pathogens from one area of the body to another.

Evaluation After 5 days of nursing intervention, client was able to: Goal met. The patient was able to be free from infections brought by harmful microorganisms as evidenced by normal vital signs and absence of purulent drainage in her surgical wound. Goal met. Risk for infection is recognized early by the patient and as a result, she puts more precaution with her personal hygiene and she’s a good compliance with her medicine.

- Encourage intake of proteinand calorie-rich foods. - Educate patient of importance of frequent hand washing and teach other caregivers to wash hands before contact with patient and between procedures with patient.

Wellness: - With family support. - Religious

NANDA Definition: At increased risk for being invaded by pathogenic organisms

b. Risk for infection is recognized early to allow for prompt treatment.

COLLABORATIVE - Consult with physician or occupational therapist

- Prescription of medicine and useful in formulating exercises.

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