ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION

SUBJECTIVE SHORT TERM INDEPENDENT SHORT TERM

- Fluid volume -Within 1-2 hours After 2 hours of
Deficit related to of nursing 1. Assess vital 1. To determine if nursing
blood loss intervention the signs. intravascular fluid intervention the
evidenced by client’s vital signs deficit exists. clients vital sign is
decrease RBC, will be in normal in normal range
hemoglobin, range such as as evidenced by
OBJECTIVE hematocrit & HR: 130 bpm to 2. Assess skin 2. Changes in HR: 100bpm and
-RBC: 3.29 10^6 platelet count. 100 bpm; color and moisture, these signs BP:110/80 mmHg
u/L BP:130/90 to urinary output, indicate blood
-Hemoglobin: 110/80 mmHg level of loss affecting LONG TERM
10.4b g/dL consciousness systemic
-Hematocrit: 31 % LONG TERM circulation. After 2 days of
-Platelet count: Within 1-2 days nursing
112 10^3 u/L of Nursing 3. Review 3. For baseline interventions the
-HR: 130 bpm Intervention the Laboratory data data and goals had been
-BP: 130/90 patient will such as CBC comparison completely met
maintain a before and after as evidenced by
normal blood blood transfusion the client
count as well as maintaining a
normal heart rate DEPENDENT normal blood
and blood 4. Administer anti- 4. To promote count and vital
pressure. coagulant clotting time and signs.
medications as prevent bleeding.
prescribed.

5. Provide blood 5. Increase

transfusion as oxygen capacity
prescribed. of blood and
blood
replacement