Don Mariano Marcos Memorial State

University South La Union Campus

COLLEGE OF COMMUNITY HEALTH AND ALLIED
MEDICAL SCIENCES
Agoo, La Union
Tel. 072.682.0663/ichams.dmmmsu-sluc.com
Embracing World Class Standards Nursing Department Care to learn, Learn to care

NURSING CARE PLAN

ASSESSMENT EXPLANATION OF OBJECTIVES INTERVENTIONS RATIONALE EVALUATION

THE PROBLEM
Objective: STO: STO:
If blood pressure After 2 hours of THERAPEUTIC After 2 hours of
Vital Signs: drops too low, the nursing  Administer oxygen by  To maximize nursing
BP: 86/50 mmHg body's vital organs do intervention, the appropriate route. oxygenation of tissues. intervention, the
MAP: 58 mmHg not get enough oxygen patient’s blood patient’s blood
HR: 122 bpm and nutrients. pressure will  Administer fluids,  To rapidly restore or pressure did not
CVP: 4 bpm return to normal electrolytes, colloids, sustain circulating return to normal
RR: 32 bpm When sepsis occur, values blood or blood products volume, electrolyte values
SVR: 640 a systemic response as indicated. balance and prevent
dynes/sec/m-5 takes place and all the shock state. GOAL UNMET.
SpO2 :90% on blood vessels dilate
Room Air causing the blood to  Provide nutrition by best  To provide foods rich in
drop. If it gets too low, means (oral, enteral or nutrients, vitamins and
Laboratory Results: it can become life- LTO: parenteral feeding) or minerals needed to LTO:
WBC: threatening, leading to After 2 days of refer to nutritionist or promote healing and After 2 days of
22,000/mcL shock. nursing dietitian. support immune system nursing
Lactic Acid: 3.6 intervention, the health. intervention, the
mmol/L patient will patient was able
Urine: cloudy with a) display to
sediment hemodynamic  For timely evaluation and a) display
 Identify reportable signs
stability as and symptoms, including intervention. hemodynamic
ABGs evidenced by vital unrelieved pain, stability as
pH: 7.22 signs within unresolved bleeding, evidenced by vital
pCO2 :30 mmHg normal range for excessive fluid loss, signs within
HCO3 :16 mEq/L client; persistent fever and chills, normal range for
pO2 :64 mmHg b) prompt capillary change in skin color client;
*Metabolic Acidosis, refill; accompanied by chest b) prompt capillary
partially compensated c) adequate urinary output pain. refill;
with normal specific gravity; c) adequate
usual level of mentation.  To reduce risk of urinary output with
Nursing Diagnosis: anaphylactic shock state normal specific
Risk for shock gravity; usual level
related to of mentation.
hypotension

GOAL MET.