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  • NCP On APD.

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    Angel Respicio
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    The patient reported nausea, frequent thirst and weakness. Vital signs were normal but physical exam found pallor and weakness. The nurse assessed the patient to be at risk for aspiration and dehydration due to fluid loss from vomiting. The plan was for the patient to have no nausea or vomiting within 8 hours and maintain fluid volume as shown by moist mouth. Interventions included monitoring signs and symptoms, providing fluids and diet, oral hygiene and positioning for comfort. The evaluation was that after 8 hours the patient would have no nausea or vomiting and verbalize comfort.

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    NCP on APD.

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    The patient reported nausea, frequent thirst and weakness. Vital signs were normal but physical exam found pallor and weakness. The nurse assessed the patient to be at risk for aspiration and dehydration due to fluid loss from vomiting. The plan was for the patient to have no nausea or vomiting within 8 hours and maintain fluid volume as shown by moist mouth. Interventions included monitoring signs and symptoms, providing fluids and diet, oral hygiene and positioning for comfort. The evaluation was that after 8 hours the patient would have no nausea or vomiting and verbalize comfort.

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    221 views2 pages

    NCP On APD.

    Uploaded by

    Angel Respicio
    The patient reported nausea, frequent thirst and weakness. Vital signs were normal but physical exam found pallor and weakness. The nurse assessed the patient to be at risk for aspiration and dehydration due to fluid loss from vomiting. The plan was for the patient to have no nausea or vomiting within 8 hours and maintain fluid volume as shown by moist mouth. Interventions included monitoring signs and symptoms, providing fluids and diet, oral hygiene and positioning for comfort. The evaluation was that after 8 hours the patient would have no nausea or vomiting and verbalize comfort.

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    Nursing process SUBJECTIVE SUBJECTIVE "Nagsuka ako ng konte." "Medyo madalas ako -as verbalized mauhaw at by the patient.

    nanghihina." -as verbalized by the patient.

    OBJECTIVE OBJECTIVE Vital signs taken as Vital signs follows: taken as BP: 100/70 follows: Temp: 36.5 C BP: 100/70 PR: 70 36.5 C Temp: RR: 68 PR: 19 RR: 20 -pallor -body weakness -dry mouth

    ASSESSMENT ASSESSMENT - Increased risk of aspiration -Deficient fluid due to vomiting, volume related relatedof fluid to loss to ulcer. through abnormal route.

    PLANNING PLANNING Within the shift, the patient will Within 8 hours have no of nursing evidence of interventions, nausea andwill the patient vomiting. fluid maintain volume as evidenced by moist mucous membrane.

    INTERVENTION INTERVENTION - Assess, report, and record -Maintain signs andrecord accurate symptoms and of intake and reactions to output. Assess treatment. skin and mucous - Monitor fluids membrane. input and output closely. -Perform frequent oral -Provide hygiene. prescribed diet avoid irritating -Encourage fluid foods, coffee, intake and etc. promote intake of high water -Encourage content foods. patient to assume position of comfort. -Encourage small frequent meals.

    EVALUATION EVALUATION -After the shift, patient will -After 8 hours of have no nursing evidence of interventions, nausea and the patient vomiting and be maintained fluid able to at volume verbalize level functional comfort. as evidenced by moist mucous "Hindi ako membrane. nagsuka ngayon."

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