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  • Date Cues Nursing Diagnosis Scientific Basis Goal of Care Nursing Intervention Rationale Evaluation

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    kimglaidyl bontuyan
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    The patient presented with signs and symptoms of fluid volume deficit including pale skin, fatigue, and stress. A nursing diagnosis of fluid volume deficit related to excessive vascular loss secondary to bleeding was made based on the definition, pathophysiological basis, and rationale. The goal of care was for the patient to maintain fluid volume at a functional level after 3 days of nurse-patient interaction through monitoring vital signs, skin turgor, and urine output. Evaluation after 3 days found the patient was able to maintain fluid volume as evidenced by stable vital signs and good skin and urine measures.

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    Fluid volume deficit ncp

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    The patient presented with signs and symptoms of fluid volume deficit including pale skin, fatigue, and stress. A nursing diagnosis of fluid volume deficit related to excessive vascular loss secondary to bleeding was made based on the definition, pathophysiological basis, and rationale. The goal of care was for the patient to maintain fluid volume at a functional level after 3 days of nurse-patient interaction through monitoring vital signs, skin turgor, and urine output. Evaluation after 3 days found the patient was able to maintain fluid volume as evidenced by stable vital signs and good skin and urine measures.

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    94 views2 pages

    Date Cues Nursing Diagnosis Scientific Basis Goal of Care Nursing Intervention Rationale Evaluation

    Uploaded by

    kimglaidyl bontuyan
    The patient presented with signs and symptoms of fluid volume deficit including pale skin, fatigue, and stress. A nursing diagnosis of fluid volume deficit related to excessive vascular loss secondary to bleeding was made based on the definition, pathophysiological basis, and rationale. The goal of care was for the patient to maintain fluid volume at a functional level after 3 days of nurse-patient interaction through monitoring vital signs, skin turgor, and urine output. Evaluation after 3 days found the patient was able to maintain fluid volume as evidenced by stable vital signs and good skin and urine measures.

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    NURSING SCIENTIFIC GOAL OF NURSING

    DATE CUES RATIONALE EVALUATION


    DIAGNOSIS BASIS CARE INTERVENTION

    March ROS Fluid Definition Of After 3 INDEPENDEN After 3 days of


    17, - Patient is volume The Nursing days of T - CVP nurse-patient
    2021 uneasy, looks deficit Dx nurse- - Monitor vital measurement interaction, the
    pale and related to patient signs and CVP. s are helpful patient was able
    tired. excessive It is defined in determining
    interacti to:
    vascular as a state or the degree of
    on, the
    - Patient loss fluid deficit - maintain fluid
    condition of patient
    experienced secondary and response volume at a
    the body will be
    fatigue and to to functional level
    where the able to: replacement
    showed signs bleeding as evidenced by
    of stress and fluid output therapy.
    exceeds the - stable vital signs,
    restlessness. Fever
    fluid intake. maintai good skin turgor,
    increases
    n fluid metabolism good capillary
    Assessment Pathophysiol volume and refill, moist
    -Skin: cold ogical Basis at a exacerbates mucous
    and moist. function fluid loss. membranes and
    -The client Decreased al level - Monitor urine adequate urinary
    responds to intravascular as output. output with
    , interstitial, evidenc - A decreased normal specific
    questions
    urinary output
    slowly and and/or ed by gravity.
    may indicate
    stares intracellular stable hypovolemia,
    blankly. fluid. Fluids vital insufficient
    are always in signs, renal
    Diagnostic flux through good perfusion or
    Studies a variety of skin polyuria can
    regulatory turgor, be present,
    Complete mechanisms good requiring
    Blood Count to maintain capillary more
    (CBC) appropriate refill, aggressive
    concentratio moist - Palpate fluid
    - Blood replacement.
    ns mucous peripheral
    Pressure: throughout membra pulses; - Conditions
    140/90 the various nes and Observe for that contribute
    compartment adequat skin color, to
    mm/Hg
    s of the e temperature, extracellular
    - body. urinary and capillary fluid deficit
    Hemoglobin- output refill. can result in
    12.8 g/dl Rationale with inadequate
    (Low) normal organ
    Body fluids specific perfusion to
    - Hematocrit- contain vital all areas and
    37.3% (Low) gravity.
    electrolytes may cause
    and circulatory
    Urine essential DEPENDENT collapse and
    Analysis minerals that shock.
    enable the - Monitor
    - laboratory
    Transparency body to
    studies, as
    - Foamy/ function - Depending
    indicated.
    Cloudy properly and on the degree
    maintain of fluid loss,
    homeostasis differing
    . These are electrolyte
    essential for and metabolic
    body imbalances
    may be
    temperature
    present and
    regulation, - Administer IV require
    muscle solutions, as correction.
    movement indicated:
    and - To help
    maintaining maintain a
    blood ph patient's
    levels. hydration,
    electrolyte
    and blood
    sugar levels.

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