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  • Assessment Diagnosis Planning Intervention Rationale Evaluation

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    tmix017
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    The document outlines an assessment, diagnosis, planning, intervention, rationale and evaluation for a patient experiencing vaginal bleeding for almost 2 months. The objectives are to address risk for blood volume deficit, hyperthermia and ineffective tissue perfusion related to blood loss. The planning involves nursing interventions over 4 hours to position the patient comfortably, monitor vitals, give IV fluids and blood transfusion as prescribed to replace fluid and blood loss. The rationale is to decrease bleeding, establish baseline data and provide comfort. The evaluation shows the interventions were effective in stopping bleeding and replacing lost blood and fluids.

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    froilan

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    The document outlines an assessment, diagnosis, planning, intervention, rationale and evaluation for a patient experiencing vaginal bleeding for almost 2 months. The objectives are to address risk for blood volume deficit, hyperthermia and ineffective tissue perfusion related to blood loss. The planning involves nursing interventions over 4 hours to position the patient comfortably, monitor vitals, give IV fluids and blood transfusion as prescribed to replace fluid and blood loss. The rationale is to decrease bleeding, establish baseline data and provide comfort. The evaluation shows the interventions were effective in stopping bleeding and replacing lost blood and fluids.

    Copyright:

    Attribution Non-Commercial (BY-NC)
    Download as DOCX, PDF, TXT or read online from Scribd
    Flag for inappropriate content
    14 views4 pages

    Assessment Diagnosis Planning Intervention Rationale Evaluation

    Uploaded by

    tmix017
    The document outlines an assessment, diagnosis, planning, intervention, rationale and evaluation for a patient experiencing vaginal bleeding for almost 2 months. The objectives are to address risk for blood volume deficit, hyperthermia and ineffective tissue perfusion related to blood loss. The planning involves nursing interventions over 4 hours to position the patient comfortably, monitor vitals, give IV fluids and blood transfusion as prescribed to replace fluid and blood loss. The rationale is to decrease bleeding, establish baseline data and provide comfort. The evaluation shows the interventions were effective in stopping bleeding and replacing lost blood and fluids.

    Copyright:

    Attribution Non-Commercial (BY-NC)
    Download as DOCX, PDF, TXT or read online from Scribd
    Flag for inappropriate content
    of 4

    Assessment Diagnosis Planning Intervention Rationale Evaluation

    Objective: Risk for blood Within the care -Position the patient in -to decreased the At the end of the care
    volume deficit of the nurses and slightly T-burg bleeding of the patient provided by the nurses and
    -vaginal bleeding related to vaginal doctors the position doctors in the hospital the
    almost 2 months bleeding for patient bleeding -Assess for the pain -to know what could be patient bleeding was stop
    -decreased almost 2 months will slightly felt by the patient the intervention and the patient blood loss
    hemoglobin and decrease every -to have the baseline data will was replaced
    hematocrit count single hour of -Monitor the VS
    -Vital Sign care
    BP: 110/70 -give IV line -to replace the electrolyte
    RR:17 prescribed by the and fluid loss
    PR:72 Doctor
    Temp:39.9
    - -give blood
    transfusion ordered by -to replace the loss blood
    the doctor
    Assessment Diagnosis Planning Intervention Rationale Evaluation

    Objective: Hyperthermia After four hours -Position the patient -to have a comfortable After four hours of nursing
    related to vaginal of nursing well comfortable position and to establish intervention the patient fever
    -Fever bleeding intervention the position comfort to the patient 39.9C was subside into 37.C
    -Vital Sign patient fever
    BP: 110/70 39.9C will -Monitor the VS every -to have the baseline data
    RR:17 subside 30 minutes
    PR:72
    Temp:39.9 -increase fluid intake -to increase metabolic
    -flushed skin and -promote well response and to avoid
    warm to touch ventilated room dehydration
    -restlessness
    -provide well -to give comfort to the
    comfortable cloths patient when she is
    moving
    Assessment Diagnosis Planning Intervention Rationale Evaluation

    Objective: Ineffective tissue After four hours -Position the patient -to establish comfort and After four hours of nursing
    perfusion related of nursing care well comfortable to reduce body weakness care the patient was
    - body weakness to decrease the patient will position establish movements and
    -dependent on hemoglobin and establish can verbalize her feelings
    others care hematocrit count movement and -assess the patient for -to monitor the and she understands her
    -lethargic secondary to verbalize her CBC hemoglobin and condition
    -pale skin vaginal bleeding feelings and she hematocrit count
    -low hemoglobin will understand
    and hematocrit her condition -Monitor the VS -to have the baseline data
    count
    -Vital Sign -provide form of -to reduce the body
    BP: 110/70 relaxation weakness of the patient
    RR:17
    PR:72 -give medication as -to promote recovery
    Temp:36 prescribe
    -

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