1461 NCP Nursing Dx sheet sample.pdf

1461 NCP Nursing Dx sheet sample.pdf - NAME PRIORITY 3...

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NAME: ______________________________ PRIORITY # 3 PATIENT NAME: __ T.G. __________ NURSING CARE PLAN Nursing Diagnosis Definition: The state in which an individual who is not NPO experiences or is at risk of experiencing vascular, interstitial or intracellular dehydration. DATA NURSING DIAGNOSIS Nursing Diagnostic Label Risk for fluid volume deficit MEASURABLE EXPECTED PATIENT OUTCOME The patient will: Not develop a fluid volume deficit NURSING INTERVENTION Assess number of pads used and fluid loss every shift NURSING INTERVENTION Assess vital signs Q4H NURSING INTERVENTION Assess skin temp, turgor and color, mucous membranes every shift SUBJECTIVE: Patient reports leakage of light pink fluid. OBJECTIVE: Patient’s pad shows leakage of blood and fluid. Ferrous sulfate 105 mg. po every day Weight 128 lbs. Height 4ft. 11 in. RBC 3.42 (low) HGB 8.6 (low) HCT 25.8 (low) RELATED FACTOR (etiology) Bleeding Secondary to placenta previa AEB (for actual diagnosis) Patient’s progress toward achievement of the outcome as evidenced by: STG: Vital signs WNL, skin warm and usual color, alert and oriented X3, urine output at least 30 cc’s/hr, moist mucous membranes, cap refill <3 sec. On my shift LTG: The fetus will show no signs of distress R/T fluid volume deficit, FHT 120-160, Kickcount >3/hr Evaluation of effectiveness of the nursing intervention Effective and why
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