Patient X Age: 42 years old

Chief complaint: Difficulty of breathing

Gender: Male
Diagnosis: Retained Hemothorax s/p CTT insertion right secondary to multiple stabbed wounds

Cues ( Subjective/ Nursing Diagnosis Rationale Goal of Care Nursing Intervention Rationale Evaluation
Objective)

Objective: Risk for deficient fluid Deficient fluid volume After 8 hours of Independent: GOAL MET.
volume related to is the state in which a nursing interventions,
Post-op status: abnormal routes person has vascular, client will: 1. Measure and record Accurate After 8 hours of
Chest tube is attached (indwelling tubes, interstitial, or input and output documentation helps Nursing interventions,
to the patient. drains) intracellular 1. Demonstrate (including tubes and identify fluid losses or client demonstrated an
dehydration. adequate fluid balance drains). replacement needs adequate fluid
Unmonitored use of as evidenced by stable and influences choice balance. Client’s vital
potent diuretics, vital signs, palpable of interventions. signs are within normal
severe vomiting, and pulses of good quality, range. Pulses are
diarrhea are common normal skin turgor, 2. Monitor vital signs, Hypotension, palpable and in good
causes of dehydration. moist mucous noting changes in tachycardia, increased quality and patient has
Potential causes of membranes, and blood pressure, heart respirations may good skin turgor.
fluid loss include fever, individually rate and rhythm, and indicate fluid deficit;
diaphoresis, appropriate urinary respirations. e.g., dehydration or
hyperglycemia, output. hypovolemia.
gastrointestinal
suction, drainage 3. Note presence of Nausea may occur in
systems, ileostomy, nausea and vomiting. the presence of
fistulae, burns, blood postural hypotension
loss, hyperventilation, for fluid volume deficit.
hyperthyroidism, Vomiting may also
decreased antidiuretic follow.
hormone secretion,
diabetes insipidus, 4. Inspect dressings, Excessive bleeding can
adrenal crisis and the drainage devices at lead to hypovolemia or
diuretic phase of acute regular intervals. Asses circulatory collapse.
renal failure. wound for swelling. Local swelling may
indicate hematoma
 formation or
hemorrhage. Bleeding
into a cavity may be
Source: hidden and diagnosed
only via vital sign
Medical-Surgical depression. Client
Nursing 7th Edition by reports of pressure
Black and Hawks. sensation in affected
area.

5. Monitor skin Cool/clammy skin,

temperature, palpate weak pulses indicate
peripheral pulses. depressed peripheral
circulation and need
for additional fluid
replacement.

Dependent:
Replaces documented
1. Administer fluid loss. Timely
parenteral fluids, replacement of
blood products circulating volume
(including autologous decreases potential for
collection), and/or complications of
plasma expanders as deficit; e.g., electrolyte
indicated. Increase IV imbalance,
rate if needed. dehydration,
cardiovascular
collapse.

2. Administer
medications as
appropriate e.g.: Relieves
Antiemetics; nausea/vomiting,
which may impair
 intake and add to fluid
losses.
Medications used to
Epoetin alfa, Vitamins stimulate production
B12/C, folic acid. of RBC.