Download Careplan - Mary Beth Smart

PRIORITIZED NURSING DIAGNOSIS CARE PLAN
(Nursing Diagnosis for NCP cannot be used more than once per semester)
Clustered Data on Data Analysis will support your Nrsg Dx Statement
Clustered Data:
BP 96/70, RR 20 Reg., Apical Pulse 114 reg., Radial Pulse 114, reg., Pedal Pulse Faint Palpable bilateral, Cap. Refill <3,
SCD ordered and applied bilateral, Bilateral below waist pitting edema+2, LUE pitting edem+1 lymph edema.
Date:
3/16
3/18
RBC
3.26
2.64
Hgh
10.3
8.4
Hct
31.2
25.2
Platelets
115
38
Nursing Diagnosis:
Platelets 38,000.
Fluid Volume Deficit R/T Loss of Blood Volume AEB RBC 2.64, Hgh. 25.2, Hgb 8.4 and
Goal: Patient will have adequate Fluid Volume.
Outcomes:
(1) Patient will maintain parameters BP (Systolic) >90 <180, and (Diastolic) >50<90 every 4 hrs.
(2) Patient will maintain urine output of 30ml/hr.
(3) Patient will establish normal Hct, Hgh levels with in 5 days.
Nursing Actions
Assess or Monitor
(1)Assess VS q 4 hrs.
(2)
Assess I & O q 4 hrs.
(3)
Monitor Daily Weights
Scientific Rationale (Reason your nursing actions will prevent, solve or lessen the
stated problem) must cite work
Vital sign changes such as increase HR, decreased BP, and increased temp. are
indicators of hypovolemia. Monitoring is necessary to prevent or detect any
complications from fluid and electrolyte imbalances. Vital signs are a quick and
efficient way to monitor a patient’s condition or identifying problems and evaluating
his or her response to interventions. Vital signs and other physiological measurements
are the basis for clinical decision-making and problem solving. P&P pg. 441-442
Assess the patient’s fluid intake. Report any extreme increase or decrease in urine
volume. Am individual’s daily output generally ranges from 1200 to 1500 ml of urine.
An hourly output less then 30 ml for more than 2 consecutive hours is cause for
concern. Diarrhea is an increase in the number or stools and the passage of liquid,
unformed feces. Excess loss of colonic fluid results in serious fluid and electrolyte or
acid base imbalances. P&P pg.1052 & 1092.
Daily weights are an important indicator or fluid status. Each Kilogram (2.2lbs) of
weight gained or lost overnight is equal to 1 liter of fluid retained or loss. These fluid
gains or losses indicate changes in the amount of total body fluid, usually ECF, but do
not indicate shift between body compartments. Weigh the patient at the same time
each day with the same scale after a patient voids. P&P pg. 898
Nursing Actions
(Independent)
(4)
Observe Mucus Membranes
q 4 hrs.
(5)
Palpate peripheral pulses q 4 hrs.
Scientific Rationale (Reason your nursing actions will prevent, solve or lessen the
stated problem)
Observe the condition of skin and mucosal membranes. Observe for dry tongue and
longitudinal tongue furrows. These are symptoms of decreased body fluids.
Provide fresh water and oral fluids preferred by the client. Provide frequent oral
hygiene. Oral hygiene decreases unpleasant tastes in the mouth and allows the
client to respond to the sensation of thirst. Nursing Dx. Hand. pg. 390
When cardiac output declines significantly, peripheral pulses weaken and are
difficult to palpate. Skin that is edematous may feel cool because of fluid
accumulation and a decreased in blood flow, secondary to the pressure of the fluid.
Signs and symptoms of FVD are reflected in changes in blood pressure and force.
Lewis pg. 311, P&P pg 537
(6)
Observe for S & S of Bleeding
q 4 hrs
Signs and symptoms of bleeding may include tachycardia, postural hypotension,
normal supine blood pressure and pulse at rest. Bruising, black tarry stool, and
bleeding gums are also signs. The effects of chronic blood loss are usually related
to the depletion of iron stores and considered as iron-deficiency anemia.
Management of chronic blood loss anemia involves identifying and stopping the
bleeding. Supplemental iron may be required and blood transfusions may be
ordered. Lewis pg. 672
(7)
Central Venous Catheters are used to administer medications or fluids, obtain
blood tests and directly obtain cardiovascular measurements such as the central
venous pressure. This patient specifically uses it for her trial chemotherapy
treatments. This catheter is beneficial with highly irritating medications. Risk
factors include venous thrombosis, pneumothorax, and infection. Nursing 102
Class lecture & power pt.
Access LW Port for delivery of
medication.
(8)
Assist pt in positioning AAT.
Encourage patient to use call cell and ask for assistance in relation to sitting and
standing. Orthostatic hypotension is an increased risk factor with low levels of Hgh
and Hct. It is common with patients with low BP. Symptoms include dizziness,
light headedness, HA, Nausea, blurred vision. Having someone present when
changing positions reduces the risk for falls. Nursing 101 Class lecture.
Dependent Actions (ie MD
order)
(1)
Admin NS at 125 ml/hr per MD
order.
(2)
Obtain order for Blood
transfusion from MD.
Norman saline is an isotonic solution and therapeutic electrolyte replacement. The
goal of treatment for fluid volume deficit is to correct the underlying cause and to
replace both water and any needed electrolytes. Normal Saline is given to patients
receiving blood transfusions. Lewis pg. 309
Anemia causes weakness and tiredness. Severe cases cause shortness of breath and
rapid heart rate. Transfusions are used to keep patients number of blood cells at a
safe level. The blood type and cross test must be done. Blood transfusions are
either whole blood or individual parts depending on the patients needs. Labs and
Diag. Tests pg. 361-363
(3)
Obtain order for Potassium from
MD.
(4)
Administer Cipro 400mg IV
q 12hrs per MD.
Hypokalemia can result from abnormal loses of potassium from a shift of
potassium from ECF to ICF. The patient presented with a potassium level of 3.0.
GI tract losses of potassium secondary to diarrhea can cause hypokalemia.
Hypokalemia alters the resting membrane potential. It is most commonly
associated with reducing the excitability of cells. The most serious problems are
cardiac. Lewis pg. 315
The goal is to stop the loss that results from diarrhea. Cipro is an anti-infective. It
inhibits bacterial DNA synthesis by inhibiting DNA gyres enzyme. Cipro is to be
diluted in 0.9%NS or D5W. It is to be administered over 60 minutes in a large vein.
Assess for S&S of infection, assess for S&S of anaphylaxis, and monitor bowel
function. Davis Drug Guide
(5)
Administer Flagyl 500mg IV
q 8hrs per MD.
The goal is to stop the loss that results from diarrhea. Flagyl is an anti-infective, anti
ulcer agent. Flagyl disrupts DNA and protein synthesis in susceptible organisms.
The patients Ph needs to be 4.5-7. This drug can be infused over 30 to 60 minutes.
Assess for S&S of infection, monitor neurologic status, Monitor I&O, daily weights,
Assess for Steven Johnson syndrome. Davis Drug Guide
Referrals
Activity intolerance can be affected by fatigue; weakness, abnormal HR and BP.
Physical therapy can help the patient optimize energy conservation techniques.
Exercise maintains muscle strength and joint ROM.
1.
Refer to PT evaluation.
Teaching
(1)
Incentive spirometry 10x while
awake.
(2)
Teach S&S of Fluid Volume
Deficit
Incentive spirometry encourages voluntary deep breathing by providing visual
feedback to patient about inspiratory volume. Incentive spirometry prevents
atelectasis. O2 saturation circulating hemoglobin and increase the effectiveness of
blood that is reaching the tissues. Nursing Care Plan Guide Pg. 199
Teach patient that when normal skin is pinched, it resumes shape in seconds, it skin
remains wrinkled for 20 to 30 seconds, the pt. has poor skin turgor. Fluid can also
stretch the skin, causing it to feel taut and hard. FVD is still occuring and the fluid is
moving to the interstitial space. Dry mucus membranes, decreased dark colored urine,
increased pulse and increased temperature should all be reported to your MD. Lewis
pg. 311