Beruflich Dokumente
Kultur Dokumente
College of Nursing
Cebu City
EXPECTED OUTCOME
DEFINING CHARACTERISITICS INTERVENTION AND RATIONALE
CRITERIA
Nursing Diagnosis: Short term: Independent
Fluid Volume deficit related to intravascular to Within 8 hours of nursing
interstitial plasma leakage and bleeding secondary interventions, patient will be
1. Monitor patient for serious bleeding, such as headache with
to disease process able to demonstrate
change in responsiveness, blurred vision, hematemesis,
interventions to monitor andhypotension, tachycardia, dizziness
S: > “Gisunggo man ko te,” as verbalized correct fluid volume deficit R = To prevent occurrence of shock
O: > received lying supine on bed, awake S = Doenges, et al. 2006, page 924
> with with IVF #4 D5NSS 1L @ 25gtts/min infusing Long term: 2. Weigh patient daily, monitor intake and output
well @ right arm with 950cc remaining level Within 3 days of nursing R = To determine degree of fluid deficit
> dry mucous membrane noted interventions, patient will S = Doenges, et al. 2004, page 257
> epistaxis noted maintain fluid volume at
> passage of watery, loose stool 3 times per day functional level. 3. Monitor patient’s vital signs
noted R = In order to assess patient’s response and progress in
> irritability observed the fluid
replacement therapy
S = Doenges, et al. 2004, page 257
3.Encourage patient to increase oral fluid intake
R = To prevent valleys in fluid level
S = Doenges, et al. 2004, page 257
4. Advise patient to maintain bed rest especially during
bleeding episodes.
R = To prevent further injury
S = Doenges, et al. 2004, page 257
Sources: Collaborative
Bullock, Barbara and R. Henze.2000. Focus on 1.Administer antipyretics (paracetamol) as ordered.
Pathophysiology. Philadelphia: Lippincott R = Used to reduce fever by its central action on the
Williams and Wilkins hypothalamus.
Cuevas, et al. 2007. Public Health Nursing in the S = Doenges, at al. 2006, page 677
Philippines. 10th Edition. Philippines 2. Administer replacement fluids and electrolytes.
Doenges, Marilynn, et. Al. 2006. Nursing R = To support circulating volume and tissue perfusion
CarePlans. 6th Edition. Thailand: FA Davis S = Doenges, et al. 2006, page 289
Company 3. Provide supplemental oxygen.
Doenges, Marilynn, et. Al. 2004. Nurses’ Pocket R =To offset increased oxygen demans and consumption.
Guide. 10th Edition. Thailand: FA Davis S = Doenges, et al. 2004, page 302
Company 4. Provide high-calorie diet.
Gulanick, et al.1994.Nursing Care Plans. 3rd R = To meet increased metabolic demands.
ed.Mosby:Missouri S = Doenges, et al. 2004, page 302