Hospitalization ST: Patient will display I&O near balance during shift. LT: Patient will have stable weight and vital signs in throughout the month. 1.Measure I&O daily 2. Note signs and symptoms of dehydration. (dry mucous membranes, thirst, diluted urine 1.Monitor laboratory studies, such as sodium 2.Encourage fluid intake. Provide allowed fluids throughout 24-hour period. 1.Helps estimate fluid replacement needs (Doenges, 9 th ed., pg. 515). 2. In diuretic or postobstructive phase of renal failure, urine output can exceed 3L/day. ECF volume depletion activated the thirst center, and sodium depletion. Continued fluid losses and inadequate replacement may lead to hypovolemic state (Doenges, 9 th ed., pg. 515). 1. Large urine losses may result in sodium wasting, while elevated urinary sodium acts osmotically to increase fluid losses (Doenges, 9 th ed., pg. 515). 2.Diuretic phase of AKI may revert to oliguric phase if fluid intake is not maintained or nocturnal dehydration occurs (Doenges, 9 th ed., pg.515). -Patient’s I&O were balanced at end of shift. -Ongoing 4 4
VIII. Client Care Plan 1. Client Problem / Contributing Factors: Ulcerating mucosa of duodenum 2. Nursing Diagnosis: Risk for bleeding r/t ulcerating mucosa of duodenum 3. Priority: High 4. Theoretical Rationale: Maslow’s Hierarchy of Needs-Safety Related Factors – Defining Characteristics Client Goal – Desired Outcomes (Short term/Long term (objectively measured) Nursing Interventions Rationale for Interventions (footnote with source) Evaluation (evaluate your goal) Ulcerating mucosa of duodenum. CC of abdominal pain and black stools on admission. ST: Patient will be free from signs of bleeding today. LT: Patient will have improved lab results and stable vital signs throughout the month. 1. Note color and characteristic of stools. 2. Note patient’s individual physiological response to bleeding, such as change in mentation, weakness, anxiety, pallor, or temperature elevation. 1. Monitor vital signs; compare with client’s normal and previous readings. 2. Monitor laboratory studies: Hgb, Hct, RBC 1. The first step in managing bleeding is to determine its location in the GI tract. This can be determined by the characteristics and color of the stool (Doenges, 9 th ed., pg.
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- Fall '19
- common bile duct, bile duct, obstructive jaundice, Doenges