Assessment Diagnosis Planning Intervention Rationale Evaluation

Subjective Data: Risk for shock related STG: After 30  Investigate It could indicate STG met after 30
-none to decreased minutes of nursing reports of ischemia minutes as evidence
intravascular fluid as interventions, the increased or by the following:
evidence by TBSA of patient will display sudden pain in
Objective data: 18.25%, presence of hemodynamic body parts  RR =19
blister in left arm (2), stability as by  PR =105 bpm
 Wt= 15kg trunk (13) and left evidence:  Assess vital To assess changes  O2 = 95-100%
thigh (3 ¼), and  Vital signs signs, state of related to shock states  Temperature
 TBSA= increased pulse and within normal consciousness = 37 ° C
18.25% respiratory rate. range and mentation  Prompt
and tissue capillary refill
 Presence of  Prompt organ perfusion (2secs)
blisters on his capillary refill  UOP= 30cc/hr
left arm (2),  GCS 14
trunk (13) and  Adequate  Administer To maximize
left thigh (3 ¼) urinary output Oxygen by oxygenation of
LTG met after 24
with normal appropriate tissues
hours as evidence by:
 PR: 123 bpm specific gravity route as
 RR: 29 indicated - Warm to touch
 Temp: 37.7  Usual level of skin
mentation.  Establish To allow for
venous access generous rehydration
- Normal vital
using large- signs:
bore IV as
LTG: After 24 hours ordered  RR =19
of nursing  PR =105
intervention, the  Place foley To monitor urine
output  O2 = 95-100%
client will maintain catheter as  Temperature
maximum tissue indicated
= 37 ° C
perfusion to vital
organs as evidence  Administer To rapidly restore or
sustain circulating - Brisk capillary
by: fluids,
volume, electrolyte refill
 warm skin electrolytes or
colloid as balance and prevent
- +2 peripheral
 present and ordered. shock state pulses
strong
peripheral  Monitor for One of the most - UOP= 30cc/hr
pulses urine output, sensitive indicators of - GCS= 14
noting change in circulating
 vitals within substantially volume or poor
normal range, decreased perfusion.
output
 Alert LOC

 Urine Output
of at least  Assess vital To determine
30cc/hr signs, capillary adequate tissue
refill, skin perfusion
color and
temperature,
mentation as
well as the
quality of pulse
every two (2)
hours

 Teach client Enhances compliance

purpose, with drug regimen,
dosage, reducing individual
schedule, risk.
precautions,
and potential
side effects of
medications
given to treat
underlying
conditions
Teach caregivers
importance of good
hand hygiene, clean
environment
especially if client is
immunocompromised