H Mole Case Study

Topics: Nursing care plan, Nursing, Hypovolemia Pages: 3 (851 words) Published: December 18, 2012
Cues| Nursing Diagnosis| Objective| Nursing Intervention| Rationale | Evaluation| SUBJECTIVE:Masakit ang tyan ko..”, as verbalized by the patient.OBJECTIVES: * Guarding behavior in the abdomen * Facial mask of pain * Distraction behaviors * V/S taken as follows:T: 36.8˚CP: 83R: 17BP: 110/ 80| Acute pain r/t disease process| Within the shift, the Patient will report pain is relieved or controlled and appear to be relaxed, able to sleep and rest appropriately.| * Assess reports of pain (PQRST). Evaluate pain and its characteristics. * Provide comfort measures and diversional activities. * Encourage stress management techniques.| * Useful in monitoring effectiveness of medication and progression of healing. * Refocuses attention, promotes relaxation, and may enhance coping abilities. * To cope up with stress and activities| “Medyo masakit pa rin pero hindi na masyado tulad kanina..”, Pain is controlled to a tolerable extent as verbalized. |

Cues| Nursing Diagnosis| Objective| Nursing Intervention| Rationale | Evaluation| Subjective: N/AObjective:✰conscious and coherent✰ afebrile✰ vaginal bleeding noted| Deficient fluid volume r/t profuse vaginal bleeding| Within the shift, will be able to maintain fluid volume at a functional level as evidenced by adequate urinary output, stable vital signs, good skin turgor and prevent signs of bleeding.| * Monitor vital signs * Assess for any signs of bleeding * Instruct to report any unusualities * Encouraged to increase oral fluid intake * Provide optimal skin care with suitable emollients| * To notice any abnormalities in patient’s condition * to notice any signs of bleeding ahead of time * to know if internal bleeding is present * to prevent dehydration * to maintain skin integrity and prevent excessive dryness| Goal achieved: (-) bleeding, stable vital signs as evidenced by: T: 36.9˚CP: 85R: 20BP: 120/...
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