XI.

Nursing Care plan

Assessment Nursing Rationale Desired Outcome Nursing Intervention Justification Evaluation

Data Diagnosis
Actual and Abnormal Deficient fluid Predisposing After 2 days of INDEPENDENT After 5 days of
findings: volume related factors nursing nursing
to blood loss (44 years old, intervention, - Monitor active fluid loss - Maintain accurate input and intervention, client
Subjective data: as evidenced female, gravida 4, client will be able from wound drainage, tubes, output. was able to:
- clients says “Damo by vaginal genetic to: diarrhea, bleeding, and
ang ga gwa sa akon bleeding for predisposition) vomiting
nga dugo.” 2weeks, ↓ a. Experience a. Goal met. Patient
decreased Formation of adequate fluid - Monitor temperature - Febrile states decrease experiences
Objective data: hemoglobin tumor in the volume and body fluids through adequate fluid
- decreased and hematocrit muscles of the electrolyte perspiration and increased volume and
hemoglobin and result. uterus balance. respiration. electrolyte balance
hematocrit count ↓ - Encourage patient to drink as evidenced by
- profused Presence of prescribed fluid amounts. - Oral fluid replacement is urine output greater
menstruation vaginal bleeding indicated for mild fluid deficit. than 30 ml/hr,
NANDA ↓ - Monitor serum electrolytes normal vital signs
risk factors: Definition: Blood loss and urine osmolality and - Elevated hemoglobin and and normal skin
- multiparity Decreased ↓ report abnormal values. elevated blood urea nitrogen turgor.
- Advanced age intravascular, Decreased (BUN) suggest fluid deficit.
- financial problems interstitial, hemoglobin and Urine-specific gravity is
and/or hematocrit result b. Will be COLLABORATIVE likewise increased. b. Goal met. The
Wellness: intracellular ↓ able to identify patient was able to
- With family support. fluid. This Deficient fluid some - Assist the physician with understand the
- Religious refers to volume management to insertion of a central venous - This allows more effective importance of
dehydration, maintain health. line and arterial line as fluid administration and taking supplements
water loss indicated. monitoring. especially iron and
alone without eating nutritious
change in foods.
sodium

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Assessment Nursing Rationale Desired Outcome Nursing Intervention Justification Evaluation
Data Diagnosis
Actual and Abnormal Risk for Precipitating After 2 days of INDEPENDENT After 5 days of
findings: Infection factor nursing - Assess nutritional status, - Patients with poor nutritional nursing
related to (Presence of intervention, including weight, history of status may be anergic, or intervention, client
exposure of surgical wound) client will be able weight loss, and serum unable to muster a cellular was able to:
Subjective data: surgical ↓ to: albumin. immune response to pathogens
- client verbalizes “indi wound in the Exposure of the and are therefore more Goal met. The
ko kapangusog kay environment surgical wound to a. Patient remains susceptible to infection. patient was able to
gasakit ang gin harmful free of infection, be free from
operahan sakon” microorganisms. as evidenced by - Encourage intake of protein- - This maintains optimal infections brought
↓ normal vital signs and calorie-rich foods. nutritional status. by harmful
Objective data: Natural defense and absence of microorganisms as
- Facial expression mechanisms of purulent drainage evidenced by
indicates slight the body are from wounds, - Educate patient of - Friction and running water normal vital signs
discomfort. inadequate incisions, and importance of frequent hand effectively remove and absence of
- Limited range of ↓ tubes. washing and teach other microorganisms from hands. purulent drainage
motion Unable to protect caregivers to wash hands Washing between procedures in her surgical
- Body weakness the body or before contact with patient and reduces the risk of transmitting wound.
- Activity intolerance unable to combat between procedures with pathogens from one area of the
the invading b. Risk for patient. body to another. Goal met. Risk for
risk factors: organism infection is infection is
NANDA adequately recognized early recognized early by
- financial problems Definition: At ↓ to allow for the patient and as a
increased risk Increased prompt treatment. COLLABORATIVE result, she puts
Wellness: for being opportunity for - Consult with physician or - Prescription of medicine and more precaution
- With family support. invaded by invading occupational therapist useful in formulating with her personal
- Religious pathogenic organism exercises. hygiene and she’s a
organisms ↓ good compliance
Risk for infection with her medicine.

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