Assessment Diagnosis Planning Intervention Rationale EvaluationSubj.(none)

Obj.Change in mental state:-Restlessness-Anxious

VS:-BP- 90/50-T- 35.4-PR- 130-RR- 27

-Urine Output: 25 ml/hr-Cool clammy skin-Capillary refill <2 sec.-HCT- 57% (increased)-Platelet – 28,000-Hgb- 7mg/dl

P: Deficient Fluid Volume related toE: Active volume loss as evidenced byS: hemorrhage/ trauma.

Short Term:

After 4 hoursof nursing interventions, the patient will report understanding of causative factors for fluid volume deficit.

Long Term:

After 3 days of Nursing Interventions, the patient will maintain fluid volume at functional level AEB well hydrated, intake is equal as output, and normal skin turgor.

Independent:Establish rapport

Monitor and record VS

Assess patient’s condition

Monitor Input& Output balance

Maintain Adequate hydration, increase fluid intake

Provide frequent oral care

Determine effects of age.

Collaborative:

Administer Intravenous fluids as prescribed

To gain patients trust

To obtain baseline dataTo be aware of the patient’s condition and feeling

To ensure accurate picture of fluid status

To prevent dehydration &maintain hydration status.

To prevent from dryness

Very young and extremely elderly individuals are quickly affected by fluid volume deficit.

To deliver fluids accurately and at desired rates.

Short term:After 4 hours of nursing interventions, the patient report understanding of causative factors for fluid volume deficit.

Long Term:After 3 days of Nursing Interventions, the patient maintained fluid volume at functional level AEB well hydrated, intake is equal as output, and normal skin turgor.

Restrict solid food intake, as indicated

Discuss individual risk factors/ potential problems and specific interventions

To allow for bowel rest and to reduce intestinal workload.

To prevent or limit occurrence of fluid deficit.

Assessment Diagnosis Planning Nursing Intervention

Rationale Evaluation

Subj.The patient states “Aray ang sakit”

Obj.VS:Change in mental state:-Restlessness-Anxious

VS:-BP- 90/50

P: Acute Pain related toE: movement of bone fragments as evidenced byS: patient complaint of pain.

Short Term:

After 15-30 mins. of nursing intervention the patient will verbalize relief of pain.

Long Goal:

- After 1 hour of rendering care and interventions, the

Independent:

Assess pain characteristics

Observe or monitor signs and symptoms associated with pain, such as BP, heart rate, temperature, color and moisture

Quality, Severity, Location, Onset, Duration, Precipitating or relieving factors

Some people deny the experience of pain when present. Attention to

Short Term:

After 15-30 mins. of nursing intervention the patient verbalized relief of pain.

Long Goal:

After 1 hour of rendering care and interventions, the patient is able to

-T- 35.4-PR- 130-RR- 27

patient will be able to have an improved feeling of control and comfort.

of skin, restlessness, and ability to focus.

Respond immediately to complaint of pain.

Provide rest periods to facilitate comfort, sleep, and relaxation.

Collaborative:

Administer

associated signs may help the nurse in evaluating pain.

In the midst of painful experiences patient's perception of time may become distorted. Prompt responses to complaints may result in decreased anxiety in patient.

A quiet environment, a darkened room, and a silent phone are all measures geared toward facilitating rest.

improved feeling of control and comfort.

medication as prescribed.

Assessment Diagnosis Planning Nursing Intervention Rationale EvaluationSubj.The patient states “I feel like I’m going to die”

Obj.VS:Change in mental state:-Restlessness-Anxious

VS:

P: Anxiety related toE: stress as evidenced byS: restlessness.

Short Term:

- After 8 hrs shift of duty of rendering care and interventions, the patient will be able to understand the complications about his condition and able to control his anxiety. through proper

Independent:

Establish rapport

Provide continuity of care

Encourage patient and

To have a trusted nurse to patient relationship and to have a therapeutic communication.

Continuity of care promotes security and development of rapport.

Accurate information

Short Term:

- After 8 hrs shift of duty of rendering care and interventions, the patient is able to understand the complications about his condition and able to control his anxiety. through proper

-BP- 90/50-T- 35.4-PR- 130-RR- 27

Long Term:

- After 3-5 days of rendering care and interventions, the patient will be able to accept the reality about his condition and readily participates in activities.

S.O to verbalize concerns and fears.

Inform them that frequent assessment are routinely done to monitor her condition and don’t necessarily imply a deteriorating condition.

Repeat the information as necessary because patient and family may reduce their attention span.

Provide a comfortable And quiet environment.

about his condition reduces fear, strengthens the nurse-patient relationship and assist the patient and family to face the situation realistically.

To reassure the patient that frequent monitoring may prevent him to develop of more serious complications.

Anxiety decreases learning and attention.

A comfortable environment enhances coping mechanisms and reduces myocardial workload and oxygen consumption.

Long Term:

- After 3-5 days of rendering care and interventions, the patient is able to accept the reality about his condition and readily participates in activities.

Collaborative:

Encourage the patient and family to ask questions and bring up common concerns.

Sharing information elicits support and comfort and can relieve tension and unexpressed worries.

HYPOVOLEMIC SHOCK

A 38 year old traffic officer was admitted in the Emergency room after being hit by a bus in front of a mall. He was brought in stretcher with a broken right leg; squirting bright red blood.

Upon assessment his initial vital signs are as follows: O2 sat 86%, blood pressure 90/50, respiratory rate of 27, and pulse rate of 130 beats per minute and a temperature of 35.4 Co. The patient weight is 70kg and height of 5’8”. His skin was cold and clammy and the capillary refill was less than 2 sec. the estimated blood loss was around 1000 ml.

He was immediately hooked to O2 inhalation at 10 liters per minute and EKG reading showed his arterial blood gas reading pH=7.20, HCO3=17, CO2=36.

CBC= (4.7-6.1 /L = RBC)Hct= 57% (0.42-0.52 g/L)Hgb=7 mg/dl (140-180 g/L)

WBC= (5-10 x /L)Na+= (135 - 145 mEq/L)K+= < 3.5 mEq/1 (3.5 - 5.0 mEq/L)

His urine output from foley catheter an hour is 25ml.

He was given an IV line of D5LR 1 liter X 40 gtts/min. another line of PLR 1 liter fast drip 200 ml remaining to run for 8hrs. X-ray shows complete fracture of the right tibia.