(in priority order)
Risk for hypovolemia related to excessive fluid loss secondary to caesarean section as evidenced by:
Patient states: “I feel lightheaded and weak.”
Elevated pulse (97), blood loss from C-section of 704 mL, low hemoglobin (8.1) and hematocrit levels (24.7). (Before C-section, her hemoglobin levels were 13.1, her hematocrit levels 36). Short Term Goal
Patient will exhibit no sign/symptoms of hypovolemia (anxiety, cool, clammy skin, confusion, decreased or no urine output, general weakness, pale skin color, rapid breathing, sweating, unconsciousness) within 24 hours.
Long Term Goal
Patient’s hematocrit and hemoglobin levels will be within normal range by discharge; (12-16 for hemoglobin, and 37-47 for hematocrit).
Monitor vital signs every 2 hours on and include apical pulse.
Monitor fluid intake and output.
Monitor lab values, especially hemoglobin and hematocrit levels.
Assess skin turgor
Essential to monitoring of cardiovascular response to illness state and replacement therapy. (Cox p.162)
Determines extent of fluid loss, need for replacement, and progress of replacement therapy. (Cox p. 162)
Depending on the avenue of fluid loss, differing electrolyte and metabolic imbalances may be present and require correction. (Cox p. 162)
To determine presence of fluid volume deficit, and if present, plan appropriate interventions. (Lewis p.1043) Short term goal was met. Within 24 hours of nursing interventions, patient exhibited no sign/and symptom of hypovolemia (anxiety, cool, clammy skin, confusion, decreased or no urine output, general weakness, pale skin color, rapid breathing, sweating, unconsciousness).
Long term goal ongoing.
(in priority order)...
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