Ghiezel Anne R.

Velada BSN3 Medical and Surgical Nursing (NCM 116 RLE)

NURSING CARE PLAN

ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION

Subjective: Fluid Volume Deficit After 24 hours of 1. Assess clients 1. To determine the After 24 hours of
“hydration habits”. best approach if the
“Sumasakit ang ulo ko at related to melena nursing intervention nursing intervention
client has potential
nahihilo ako lalo na pag secondary to the patient will have the patient was able
2. Evaluate nutritional for dehydration.
tumatayo. Para akong
hinang hina, napansin ko Gastrointestinal absence of GI status, noting to defecate normal
bleeding. bleeding and have current intake and 2. This might stool color and have
na sa tatlong beses na
type of diet. negatively affect
pagdumi ko ngayong araw fluid volume at fluid intake.
fluid volume at
maitim ang kulay nito. functional level. functional level as
3. Review the client’s
Ilang taon na din pabalik Fluid volume deficit (FVD) or
baalik yung pakiramdam
medications, 3. To identify evidenced by stable
hypovolemia is a state or Gastrointestinal (GI) bleeding including medications that vital signs.
na parang may acid na condition where the fluid is a symptom of a disorder in
output exceeds the fluid prescription, over can alter fluid and
umaakyat sa sikmura ko, your digestive tract. The
intake. It occurs when the the counter drugs, electrolyte balance.
pero nitong nagdaang blood often appears in stool
body loses both water and herbs, and
araw parang mas lumala or vomit but isn't always
electrolytes visible, though it may cause nutritional 4. To evaluate fluid
ito”, as verbalized by the
the stool to look black or supplements. and electrolyte
patient. Electrolytes -mineral that tarry. The level of bleeding status.
carry electrical charge can range from mild to 4. Review laboratory
Objective: (support hydration severe and can be life- data. 5. To ensure an
threatening accurate picture of
 Alert 5. Compare current fluid status.
Depending on the amount of
 Oriented blood loss and whether you
fluid intake to fluid
 Overweight continue to bleed, you might goal. Monitor intake 6. To monitor signs of
and output (I&O) dehydration, such
 Anxious require fluids through a
needle (IV) and, possibly, balance, if as dry skin and
 Restless blood transfusions. If you indicated, being mucous
 Facial pallor and take blood-thinning aware of changes in membranes, poor
cool skin medications, including aspirin intake or output, as skin turgor, delayed
 Rounded or nonsteroidal anti- well as insensible capillary refill, and
inflammatory medications,
abdomen losses. flat neck veins.
you might need to stop.
 Hyperactive
bowel sounds NSAIDS – side effects 6. Assess skin and oral 7. Vital signs changer
Abdominal pain, heartburn, mucous may cause or be the
 Moderate
nausea, diarrhea. membranes. effect of
tenderness and dehydration.
pain upon 7. Monitor vital signs
palpation at for changes.
epigastrium
 8. Offer a variety of
 Vital Signs as fluids and water- 8. To increase the
follow: rich foods, and client’s daily fluid
make them intake.
available
Supine throughout the day, 9. To stop or limit fluid
BP: 120/80 mmhg if the client is able losses.
HR: 110 bpm to take oral fluids.
Assist/remind the 10. To reduce risk of
Upon Standing client to drink, as injury and
BP: 90/60 mmhg needed. Determine dehydration.
HR: thready individual fluid
RR: 20 cpm needs and establish 11. Some medication
replacement over24 has potential for
T: 98 F/ 36.7 C
hr. causing or
exacerbating
9. Administer dehydration.
medications as
appropriate. 12. To determine
replacement needs.
10. Discuss individual
risk 13. This enhances
factors/potential cooperation with
problems and the regimen and
specific achievement of
interventions. goals.

11. Review appropriate

use of medications.

12. Encourage the

client/caregiver to
maintain a diary of
fluid intake, number
and amount of
voidings, and
estimates of other
fluid losses as
necessary.

13. Engage
client/family, and all
caregivers in a fluid
management plan.
HISTORY OF PRESENT ILLNESS: Mr. Perez is a 55 years old executive who presents to the emergency room complaining of the passage of black stools x 3 days and an associated dizziness. He also
relates that he cannot keep up with his usual schedule because of fatigability. Upon further questioning he states that his stools are not only black, but are sticky and malodorous. He further
complains of recent worsening of a chronic epigastric burning which had been a problem off/on for years. He had doubled his usual dose of turns without significant relief of the burning. He has 2-3
martinis at lunch and another cocktail before dinner. He takes NSAIDS as needed for back pain and recently started on one aspirin per day for cardiac prophylaxis. He smokes two packs of cigarettes
per day and an occasional cigar. He was told of an ulcer in the distant past but had no specific evaluation or treatment for same.

Mr. Perez has been treated for hypertension for eight years but denies any known cardiac history. His weight is stable to increase and he claims to have an excellent appetite. He has a normal bowel
habit and has not had prior black stools. He has had no abdominal surgery and denies bleeding tendencies or prior transfusion.

PHYSICAL EXAMINATION: Examination reveals an alert, oriented, overweight male. He appears anxious and somewhat restless. Vital sips are as follows. Blood Pressure 120/80 mmHg, Heart Rate
110/min - Supine;� BP 90/60 mmHg; HR Thready - Standing (Patient complains of dizziness upon standing). Respiratory Rate - 20 /minute; Temperature 98 F.

HE-ENT/SKIN: Facial pallor and cool, moist skin are noted. Tiny blood Vessels of the lips or oral cavity are noted. The parotid glands appear full.

CHEST: Lungs are clear to auscultation and percussion. The cardiac exam reveals regular rhythm. No murmur is appreciated. Peripheral pulses are present but are rapid and weak.

ABDOMEN/RECTUM: The abdomen reveals a rounded abdomen. Bowel sounds are hyperactive. There is moderate tenderness and pain upon palpation at epigastrium; the edge feels firm. No masses
were appreciated; the exam was felt to be suboptimal secondary to the patient's obesity. Rectal examination revealed black, tarry stool.

 NSAIDS -nonsteroidal inflammatory drug, treat inflammation, moderate pain, fever (ASPIRIN)
 ASPIRIN -treat pain, fever, headache, inflammation, reduce risk of heart attack (pt. cardiac prophylaxis -inflammation of the inside lining of the heart chambers and
heart valves)
 ULCER – sores in the lining of the stomach or the small intestine
 HYPERTENSION -force of the blood against the artery walls is too high, above 140/90
 THREADY – rapid,weak
 BOUNDING -does not easily disappear with pressure
 Orthostatic hypotension -low blood pressure that happens when standing up from sitting or lying down
 DRY SKIN – low blood levels of vitamin D (regulate amount of calcium)
 MURMUR -quiet, blurred sound
 HYPERACTIVE - loud, gurgling rushed sounds () Increase intestinal activity, extremely active (diarrhea, Irritable BS)

 INSPECTION -the use of eyes to inspect

 AUSCULTATION -the use of stethoscope to hear sounds
 PALPATION -feeling with use of fingers or hands during physical examination
 PERCUSSION -striking abdomen with the use of hands to assess air filled structure

VITAMINS
A -fat soluble vitamins, important for normal visions, immune system, reproduction
B -energy levels, brain function, cell metabolism (b complex -helps prevent infection, help support or promote healthy cells
C -ascorbic acid (growth, development and repair of body tissue)
D -help regulate the amount of calcium and phosphate in the body. (keep bones, teeth and muscle healthy
K -important in blood clotting and healthy bones