NCP GRAND CASE PRE C Nursing Problems
NCP GRAND CASE PRE C Nursing Problems
NCP GRAND CASE PRE C Nursing Problems
1. Excess fluid volume related to decreased urine output, dietary excesses, and retention of sodium and water.
2. Ineffective Breathing Pattern r/t impending pulmonary congestion d/t impaired GFR and fluid retention or respiratory muscle weakness
3. Imbalanced nutrition: less than body requirements related to anorexia, nausea, vomiting, dietary restrictions, and altered oral mucous
membranes.
4. Ineffective renal tissue perfusion related to decreased hemoglobin concentration in the blood.
6. Activity intolerance related to fatigue, anemia, retention of waste products, and dialysis procedure.
1. Risk for impaired skin integrity r/t the accumulation of fluid in the interstitial space 2° imbalanced nutritional state
NURSING CARE PLAN
Name of Patient: L.R. C. M. Ward/Bed Number: 3010 - 1 Attending Physician: Dr. V.
Age/Sex: 23/M Impression/Diagnosis: Breast CA Stage 2 w/ pulmonary & Brain metastasis; CAP HR w/o Hypoxemia; DM Type 2
15. Review lab data like BUN, 15. To monitor kidney function
Creatinine, Serum
electrolyte.
NURSING CARE PLAN
Name of Patient: L.R. C. M. Ward/Bed Number: 3010 - 1 Attending Physician:Dr. V.
Age/Sex: 34/F Impression/Diagnosis: Breast CA Stage 2 w/ pulmonary & Brain metastasis; CAP HR w/o Hypoxemia; DM Type 2
11. Taught about foods what & 11. To make him aware about his >verbalize
not what to eat (↓protein, Na & diet that is needed for his understanding of
nourishment. causative factors
fluid restriction, ↑ fats & when known and
carbohydrates = calories). necessary
interventions.
DEPENDENT:
Aminovita Capsule works by
Administer aminoVita 1 cap. 3x a providing nutritional
day as ordered. requirements of the body to
maintain physiological balance;
promoting protein synthesis and
wound healing.
COLLABORATIVE:
To set nutritional goals when
Collaborate to interdisciplinary client has specific dietary needs.
team including the dietician and
nutritional support team.
NURSING CARE PLAN
Name of Patient: L.R. C. M. Ward/Bed Number: 3010 - 1 Attending Physician: Dr. V.
Age/Sex: 34/F Impression/Diagnosis: Breast CA Stage 2 w/ pulmonary & Brain metastasis; CAP HR w/o Hypoxemia; DM Type 2
Medical – Surgical
Nursing (2008) 4th Ed.
By LeMone, P. & Burke,
K.
NURSING CARE PLAN
Name of Patient: L.R. C. M. Ward/Bed Number: 3010 - 1 Attending Physician: Dr. V.
Age/Sex: 34/F Impression/Diagnosis: Breast CA Stage 2 w/ pulmonary & Brain metastasis; CAP HR w/o Hypoxemia; DM Type 2