Nationality : Gender: Date and Time of Admission: Impression/Diagnosis : Occipital mass secondary to liver metastasis; Anemia secondary to occipital mass
Date Cues/Data Nursing Scientific Basis Goal of Nursing Rationale Evaluation
Diagnosis Care Intervention August Subjective: Deficient Definition: After 45 After 45 19, -prior to fluid Decreased minutes of minutes of 2010 admission, he volume intravascular, nurse- nurse-client experienced related to interstitial, client interaction, bleeding hemorrhag and/or interaction the client -2nd operation e intracellular fluid. , the client was able to: was stopped due This refers to will be able to hemorrhage dehydration, to: -assess vital -to obtain a.Elicit signs -abrupt change water loss alone signs baseline of of position without change a.Elicit -weigh the data developmen triggers bleeding in sodium. signs of client -to know the t developme extent of -bleeding Objective: Relationship of nt -stop blood fluid loss has stopped -consumed 3 L Problem to loss -to avoid -patient is PNSS Etiology: -administer severe fluid comfortable -consumed 2 Hemorrhage is fluids as volume bags of PRBC an active fluid b.Start indicated. deficit b.Start fluid and still need to volume loss that fluid Replace -to volume secure another was not properly volume blood effectively replacement -took 7 seconds replaced. Excess replaceme products as and quickly therapy as for his toenail to in blood loss nt therapy ordered replace fluid evidenced refill does not only -control by: -fingernails and contain the RBC humidity -to prevent -increase of toenails were but also the -position excess oral fluid pale other client sweat intake -bp: 100/50 compartments of comfortably adding to - mmHg the blood. -note insensible attachments -palpebral and client’s water loss of IV fluid bulbar Own Analysis: preference -to minimize -started conjunctiva were If too much blood of food high pressure on blood pale is lost, the body in fluid the wound transfusion tries to -keep fluid -to aid in -decreased Hgb compensate but within reach fluid 6.0 because this loss and replacement -decreased Hct is in extent and encourage -to avoid 0.18 was not properly intake client from replaced the doing Repeat blood body can no unnecessary test longer things -decreased RBC compensate thus 3.26 M/UL resulting to -decreased Hgb deficit in fluid 8-6 L g/dl volume. Pale skin -decreased Hct and delayed refill 26% are some of the -decreased MCH manifestations; 25 Pg this is due to decrease supply of blood. Blood is also helpful in fighting off foreign materials that is present in the impaired skin integrity resulting to increased workload or function of the blood.
Source: Marilynn E. Doenges et. Al, Nurse’s Pocket Guide Diagnoses, Prioritized Interventions and Rationales edition II, page published by FA Davis Company