Name: Marilyn Galico Secondary to Chronic Blood Loss Secondary to Submucous Myoma Age: 42 years old NURSING DIAGNOSIS

Fluid volume deficit related to excessive blood loss as evidenced by post BT of PRBC 6 units and verbalization of persistent heavy

Attending Physician: Dr. Dazo, Dr. Jurueuena, Dr. Mutia Ward: Gyne Ward Bed: Bed 9 NURSING OBJECTIVES After my 8-hour nursing intervention, the patient must be able to: Avoid reoccurrence of bleeding, thus achieving and maintaining body fluid volume within normal range as evidenced by: Elimination of skin pallor Maintenance of a NURSING INTERVENTION 1.Establish rapport to the client and significant others To gain trust and confidence, thus facilitating cooperation and easy implementation of the planned intervention. 2.Assess vital signs Such will establish a baseline data for the Good skin turgor Moist mucous GOAL MET 04-18-12 03:00pm After my 8-hour implementation of nursing care, the client was able to: To achieve and maintain a body fluid volume within normal range as evidenced by: NURSING EVALUATION

DATE/TIME

NURSING CUES Natingala ko nga kusog

NEED

N U T R I O

April 18, 2012

na kayo akong pagdugo. Unya sa una moundang mani pagkahuman sa nuybe kaadlaw pero nagpadayon man siya hangtod naluspad ug

7-3

bleeding for 15 days with

N
naluya nalang kog taman. as verbalized by patient. Objective: Heavy bleeding 6 fully soaked sanitary

A L M E

napkins per day.

for 15 days with 6 fully soaked sanitary napkins per day Post blood transfusion 6

T A B O L I
-

good skin turgor Moistening of mucous membranes Balanced intake and output Fast capilliary refill

intervention planning and as for future evaluations. 3. Provide proper ventilation and calm environment To avoid other fluid loss through excessive sweating 4. Instruct client to increase oral fluid intake To maintain proper hydration status 5. Administer ferrous sulfate 300mg OD as ordered For further treatment of the clients condition -

membranes Absence of general pallor Balanced intake and output with 700cc intake and 520 output Good capillary refill of 2 seconds

units of PRBC

C
Medicated with ferrous sulfate 300mg OD

P A T T E R N

General pallor noted

Capillary refill of 4 seconds

Hemoglobin of 93

Coldness of the skin noted

Dry oral mucous membrane

via pharmacologic intervention. 6. Instruct client to eat green leafy vegetables To increase hemoglobin level 7. Observe for fever, changes in level of consciousness, poor skin turgor, dryness of skin and mucous membranes, and pain. Symptoms are reflective of dehydration and hemoconcentration with consequent casoocclusive state. 8. Administer IV fluids

as ordered. To replace fluid deficits thus reversing renal concentration of RBCs. 9. Monitor every 4 hours intake and output. To ensure and reevaluate proper body fluid volume.