Nursing Care plan Assessment Data Actual and Abnormal findings: Subjective data: Nursing Diagnosis Deficient fluid

volume related to blood loss as evidenced by vaginal bleeding, decreased hemoglobin and hematocrit result. Desired Outcome After 2 days of nursing intervention, client will be able to: a. Experience adequate fluid volume and electrolyte balance. Nursing Intervention INDEPENDENT - Monitor active fluid loss from wound drainage, tubes, diarrhea, bleeding, and vomiting - Monitor temperature - Maintain accurate intake and output. a. Goal met. Patient experiences adequate fluid volume and electrolyte balance as evidenced by urine output greater than 30 ml/hr, normal vital signs and normal skin turgor. b. Goal met. The patient was able to understand the importance of taking supplements especially iron and eating nutritious foods. Justification Evaluation After 5 days of nursing intervention, client was able to:

Objective data: - decreased hemoglobin and hematocrit count - profuse menstruation

- Febrile states decrease body fluids through perspiration and increased respiration. - Oral fluid replacement is indicated for mild fluid deficit. - Elevated hemoglobin and elevated blood urea nitrogen (BUN) suggest fluid deficit. Urine-specific gravity is likewise increased. - This allows more effective fluid administration and monitoring.

- Encourage patient to drink prescribed fluid amounts. - Monitor serum electrolytes and urine osmolality and report abnormal values. COLLABORATIVE

NANDA Definition: Decreased intravascular, interstitial, and/or intracellular fluid. This refers to dehydration, water loss alone without change in sodium

b. Will be able to identify some management to maintain health.

- Assist the physician with insertion of a central venous line and arterial line as indicated.

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Assessment Data Actual and Abnormal findings: Subjective data:

Nursing Diagnosis Risk for Infection related to exposure of surgical wound in the environment

Desired Outcome After 2 days of nursing intervention, client will be able to: a. Patient remains free of infection, as evidenced by normal vital signs and absence of purulent drainage from wounds, incisions, and tubes.

Nursing Intervention INDEPENDENT - Assess nutritional status, including weight, history of weight loss, and serum albumin.

Justification - Patients with poor nutritional status may be unable to muster a cellular immune response to pathogens and are therefore more susceptible to infection. - This maintains optimal nutritional status. - Friction and running water effectively remove microorganisms from hands. Washing between procedures reduces the risk of transmitting pathogens from one area of the body to another.

Evaluation After 5 days of nursing intervention, client was able to: Goal met. The patient was able to be free from infections brought by harmful microorganisms as evidenced by normal vital signs and absence of purulent drainage in her surgical wound. Goal met. Risk for infection is recognized early by the patient and as a result, she puts more precaution with her personal hygiene and shes a good compliance with her medicine.

Objective data: - Facial expression indicates slight discomfort. - Limited range of motion - Body weakness - Activity intolerance

- Encourage intake of proteinand calorie-rich foods. - Educate patient of importance of frequent hand washing and teach other caregivers to wash hands before contact with patient and between procedures with patient.

b. Risk for infection is recognized early to allow for prompt treatment.

COLLABORATIVE - Consult with physician or occupational therapist

- Prescription of medicine and useful in formulating exercises.

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