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    Casepres NCP

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    dencio1992
    The nursing documentation summarizes the assessment, nursing diagnosis, planning and interventions, and evaluation for a patient presenting with signs of anemia and risk of infection. The nurse established rapport, monitored vital signs and symptoms, advised on hand washing and mask use to prevent infection, and encouraged exercises and diet. After interventions, the patient was able to identify risk reduction strategies. A second patient presented with fluid deficiency from upper GI bleeding. The nurse monitored fluids and symptoms, advised rest and clear liquids. Both patients demonstrated improved conditions after nursing care.

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    Casepres NCP

    Uploaded by

    dencio1992
    1K views6 pages
    The nursing documentation summarizes the assessment, nursing diagnosis, planning and interventions, and evaluation for a patient presenting with signs of anemia and risk of infection. The nurse established rapport, monitored vital signs and symptoms, advised on hand washing and mask use to prevent infection, and encouraged exercises and diet. After interventions, the patient was able to identify risk reduction strategies. A second patient presented with fluid deficiency from upper GI bleeding. The nurse monitored fluids and symptoms, advised rest and clear liquids. Both patients demonstrated improved conditions after nursing care.

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    casepres ncp

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    The nursing documentation summarizes the assessment, nursing diagnosis, planning and interventions, and evaluation for a patient presenting with signs of anemia and risk of infection. The nurse established rapport, monitored vital signs and symptoms, advised on hand washing and mask use to prevent infection, and encouraged exercises and diet. After interventions, the patient was able to identify risk reduction strategies. A second patient presented with fluid deficiency from upper GI bleeding. The nurse monitored fluids and symptoms, advised rest and clear liquids. Both patients demonstrated improved conditions after nursing care.

    Copyright:

    Attribution Non-Commercial (BY-NC)
    Download as DOCX, PDF, TXT or read online from Scribd
    Download as docx, pdf, or txt
    1K views6 pages

    Casepres NCP

    Uploaded by

    dencio1992
    The nursing documentation summarizes the assessment, nursing diagnosis, planning and interventions, and evaluation for a patient presenting with signs of anemia and risk of infection. The nurse established rapport, monitored vital signs and symptoms, advised on hand washing and mask use to prevent infection, and encouraged exercises and diet. After interventions, the patient was able to identify risk reduction strategies. A second patient presented with fluid deficiency from upper GI bleeding. The nurse monitored fluids and symptoms, advised rest and clear liquids. Both patients demonstrated improved conditions after nursing care.

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    ASSESSMENT NURSING INFERENCE PLANNING NURSING RATIONALE EVALUATION


    DIAGNOSIS INTERVENTIONS
    SUBJECTIVE: RISK FOR ANEMIA After 4 hours -established rapport - to gain trust After 4 hours
    INFECTION of nursing and relieve of nursing
    RELATED TO interventions, anxiety interventions
    OBJECTIVE: INCREASE WBC DECREASE the client will the client
    -the client COUNT OXYGEN IN identify -monitor vital sign, -to have a identify the
    manifested the THE BLOOD interventions especially temperature baseline- proper self-
    following signs to management
    and symptoms: reduce/preve -stress proper hand -hand to reduce the
    rWBC nt risk for washing techniques by washing is risk of having
    -pale and cool infection all caregivers the primary infection
    skin measure
    -weakness RISK FOR against
    -easy INFECTION nosocomial
    fatigability infection/cro
    -dryness of lips ss
    -with ongoing contaminatio
    n
    -with limited -reverse
    range of -advice the use of facial isolation is
    maotion mask when interacting to an important
    -labs suggest a other for clients
    increased in who are
    WBC count, immuno-
    eosinophils, suppressed
    monocytes and -simple
    a decreased of -encouraged early exercises
    hematocrit and ambulation, deep helps to tone
    hemoglobin breathing exercises as the body and
    indicated strengthen
    the body
    system

    -reinforced teachings -to provide


    VS TAKEN AS about diet. Avoid raw optimum
    FOLLOWS: meats, fruits and nutrition to
    vegetables. Consume meet daily
    T- 36.8C prescribed adequate needs of the
    P- 80 cpm menus. client, raw
    RR- 19 bpm foods can
    BP-120/80 contain
    mmhg microorganis
    m that may
    precipitate
    infection
    -helps
    -review to the client and alleviate
    so the nature of the anxiety; can
    disease and the also foster
    interventions needed cooperation
    and
    compliance
    to prescribed
    therapeutics

    -instruct the client to -to intervene


    report significant with such
    changes that he may events
    experience typical to a accordingly.
    presence of infection
    ASSESSMENT NURSING INFERENCE PLANNING NURSING RATIONALE EVALUATION
    SUBJECTIVE: FLUID VOLUME UPPER GI After 30 INTERVENTIONS - to gain trust After effective
    DEFICIENT BLEEDING mins of - established rapport and relieve nursing
    ³madali akong RELATED TO nursing anxiety intervention the
    mapagod tapos DECREASE intervention patient was able
    nauuhaw din´, INTRAVASCULAR gastric erosion the patient -to have a to
    as verbalized FLUID will learn -monitor vital sign, baseline demonstrate
    by the patient. SECONDARY TO the disease especially temperature - Helpful improved fluid
    UPPER GI hemorrhage process and - Note characteristics of indetermining balance as
    OBJECTIVE: BLEEDING Demonstrat vomitus or drainage. cause of evidence by
    e improved gastric individually
    -received Ñintravascular fluid distress adequate
    patient on bed fluid balance as - Monitor I and O and - Provides urinary output
    awake evidence by correlate weight guidelines for with normal
    -pale and cool individually changes. fluid specific gravity,
    to touch FLUID adequate replacement stable V/S,
    -delayed VOLUME urinary moist mucous,
    capillary refill DEFICIENCY output with - potential good skin
    (3-4 seconds) normal - Keep accurate record exits turgor, prompt
    -body specific of subtotals of or over capillary refill.
    weakness gravity, solution/blood products transfusion of
    -with ongoing stable V/S, during replacement fluids,
    IVF moist therapy. esp.when
    mucous, volume
    VS TAKEN AS good skin expanders are
    FOLLOWS: turgor, given before
    T- 36.8C prompt blood
    PR-80cpm capillary transfusion.
    RR-19pm refill.
    BP-120/80 -
    mmgh activity/vomitin
    - Maintain bed rest; g increases
    prevent vomiting and intra
    straining at stool. abdominal
    pressure and
    can
    predispose to
    further
    - Provide clear/band bleeding.
    fluids when intake is - More easily
    resumed. Avoid digested and
    caffeinated and reduce risk of
    carbonated beverages. added
    irritation to
    inflamed
    tissues.
    Caffeine and
    carbonated
    beverages
    stimulate HCL
    production,
    possibly
    potentiating
    rebleeding
    c

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