ACTUAL AND POTENCIAL NCP PEPTIC ULCER. ADEPOJU IYINOLUWA E.

ASSESSMENT EXPLANATION OF THE OBJECTIVES NURSING INTERVENTION RATIONALE EVALUATION

PROBLEM
Fluid volume deficit STG; DX; DX; STG; (Goal met)
(FVD) or
OBJECTIVE; After 30 min of nursing 1 Assess possible risk factors 1 To obtain baseline data. After 30 min of nursing
hypovolemia is a intervention the patient intervention the patient
appears weak & tired state or condition 2. Monitor and record vital 2 To obtain baseline data.
will verbalize was able to;
where the fluid signs.
water intake of understanding on fluid 3 This helps in identifying
output exceeds the demonstrated behaviors
1000ml volume deficit and 3. Assess patient’s appetite contributing factors.
fluid intake. It to monitor fluid status
increase fluid intake. 4. Assess for the signs of 4. The client with a bleeding
occurs when the and increase fluid intake
NURSING DIAGONSIS; body loses both LTG; hematemesis or melena. ulcer may vomit bright red
LTG; (Goal Met)
water and blood or coffee grounds
Risk for deficient fluid After 8 hours of Nursing
electrolytes from emesis. Melena occurs when After 8 hours of Nursing
volume related to intervention the patient
the ECF in similar there is bleeding in the upper intervention the patient
decreased oral intake demonstrates fluid
proportions. GI tract. demonstrated fluid
balance evidenced by
Common sources of balance evidenced by
individually appropriate TX; TX;
fluid loss are the individually appropriate
parameters, e.g., moist 1 To prevent fluid overload
gastrointestinal 1 Note amount/rate of fluid parameters, e.g., moist
mucous membranes, and monitor intake and
tract, polyuria, and intake from all sources mucous membranes,
good skin turgor, prompt output.
increased good skin turgor,
capillary refill, stable vital 2 Instruct the client to
perspiration. Risk 2 These assessment findings prompt capillary refill,
signs. immediately report symptoms
factors for FVD are are signs of GI bleeding and stable vital signs.
of nausea, vomiting, dizziness,
as follows: vomiting, shortness of breath, or dark should be reported
diarrhea, GI tarry stools. immediately.
suctioning, 3 Isotonic fluids, volume
3 Administer IV fluids, volume
sweating, decreased expanders, and blood
expanders, and blood products
intake, nausea, products can restore or
as ordered.
inability to gain expand intravascular volume.
access to fluids,
adrenal
ACTUAL AND POTENCIAL NCP PEPTIC ULCER. ADEPOJU IYINOLUWA E.
insufficiency, EDX; EDX;
osmotic diuresis, 1 Encourage quiet, restful 1 To conserve energy and
hemorrhage, coma, atmosphere. lower tissue oxygen demand.
third-space fluid
shifts, burns, ascites, 2. Instruct to avoid sodium and 2. To lessen fluid retention and
and liver fluid intake if indicated overload.
dysfunction. Fluid 3. Encouraged patient to 3. Verbalization of feelings in a
volume deficit may verbalize true feelings. Avoid non-threatening environment
be an acute or becoming defensive when may help patient come to
chronic condition angry feelings are directed at terms with long-unresolved
managed in the him or her. issues.
hospital, outpatient
center, or home
setting.
REF;
www.nurseslab.com
ACTUAL AND POTENCIAL NCP PEPTIC ULCER. ADEPOJU IYINOLUWA E.