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    Nursing Care Plan: Uterine Myoma

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    shiramu
    1. The patient has deficient fluid volume related to blood loss from menstruation and surgery. Nursing diagnoses include deficient fluid volume and risk for infection. 2. Through interventions like monitoring fluid intake and output, encouraging oral fluids, and ensuring nutrition, the desired outcomes of adequate fluid balance and prevention of infection will be achieved. 3. After 5 days of nursing care including monitoring vitals, wound care, nutrition, and hygiene education, the goals were met as evidenced by normal fluid balance and an infection-free surgical wound.

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    Nursing Care Plan: Uterine Myoma

    Uploaded by

    shiramu
    102K views2 pages
    1. The patient has deficient fluid volume related to blood loss from menstruation and surgery. Nursing diagnoses include deficient fluid volume and risk for infection. 2. Through interventions like monitoring fluid intake and output, encouraging oral fluids, and ensuring nutrition, the desired outcomes of adequate fluid balance and prevention of infection will be achieved. 3. After 5 days of nursing care including monitoring vitals, wound care, nutrition, and hygiene education, the goals were met as evidenced by normal fluid balance and an infection-free surgical wound.

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    1. The patient has deficient fluid volume related to blood loss from menstruation and surgery. Nursing diagnoses include deficient fluid volume and risk for infection. 2. Through interventions like monitoring fluid intake and output, encouraging oral fluids, and ensuring nutrition, the desired outcomes of adequate fluid balance and prevention of infection will be achieved. 3. After 5 days of nursing care including monitoring vitals, wound care, nutrition, and hygiene education, the goals were met as evidenced by normal fluid balance and an infection-free surgical wound.

    Copyright:

    Attribution Non-Commercial (BY-NC)
    Download as DOC, PDF, TXT or read online from Scribd
    Download as doc, pdf, or txt
    102K views2 pages

    Nursing Care Plan: Uterine Myoma

    Uploaded by

    shiramu
    1. The patient has deficient fluid volume related to blood loss from menstruation and surgery. Nursing diagnoses include deficient fluid volume and risk for infection. 2. Through interventions like monitoring fluid intake and output, encouraging oral fluids, and ensuring nutrition, the desired outcomes of adequate fluid balance and prevention of infection will be achieved. 3. After 5 days of nursing care including monitoring vitals, wound care, nutrition, and hygiene education, the goals were met as evidenced by normal fluid balance and an infection-free surgical wound.

    Copyright:

    Attribution Non-Commercial (BY-NC)
    Download as DOC, PDF, TXT or read online from Scribd
    Download as doc, pdf, or txt
    of 2

    XI.

    Nursing Care plan

    Assessment Nursing Rationale Desired Outcome Nursing Intervention Justification Evaluation


    Data Diagnosis
    Actual and Abnormal Deficient fluid Predisposing After 2 days of INDEPENDENT After 5 days of
    findings: volume related factors nursing nursing
    to blood loss (44 years old, intervention, - Monitor active fluid loss - Maintain accurate input and intervention, client
    Subjective data: as evidenced female, gravida 4, client will be able from wound drainage, tubes, output. was able to:
    - clients says “Damo by vaginal genetic to: diarrhea, bleeding, and
    ang ga gwa sa akon bleeding for predisposition) vomiting
    nga dugo.” 2weeks, ↓ a. Experience a. Goal met. Patient
    decreased Formation of adequate fluid - Monitor temperature - Febrile states decrease experiences
    Objective data: hemoglobin tumor in the volume and body fluids through adequate fluid
    - decreased and hematocrit muscles of the electrolyte perspiration and increased volume and
    hemoglobin and result. uterus balance. respiration. electrolyte balance
    hematocrit count ↓ - Encourage patient to drink as evidenced by
    - profused Presence of prescribed fluid amounts. - Oral fluid replacement is urine output greater
    menstruation vaginal bleeding indicated for mild fluid deficit. than 30 ml/hr,
    NANDA ↓ - Monitor serum electrolytes normal vital signs
    risk factors: Definition: Blood loss and urine osmolality and - Elevated hemoglobin and and normal skin
    - multiparity Decreased ↓ report abnormal values. elevated blood urea nitrogen turgor.
    - Advanced age intravascular, Decreased (BUN) suggest fluid deficit.
    - financial problems interstitial, hemoglobin and Urine-specific gravity is
    and/or hematocrit result b. Will be COLLABORATIVE likewise increased. b. Goal met. The
    Wellness: intracellular ↓ able to identify patient was able to
    - With family support. fluid. This Deficient fluid some - Assist the physician with understand the
    - Religious refers to volume management to insertion of a central venous - This allows more effective importance of
    dehydration, maintain health. line and arterial line as fluid administration and taking supplements
    water loss indicated. monitoring. especially iron and
    alone without eating nutritious
    change in foods.
    sodium

    18
    Assessment Nursing Rationale Desired Outcome Nursing Intervention Justification Evaluation
    Data Diagnosis
    Actual and Abnormal Risk for Precipitating After 2 days of INDEPENDENT After 5 days of
    findings: Infection factor nursing - Assess nutritional status, - Patients with poor nutritional nursing
    related to (Presence of intervention, including weight, history of status may be anergic, or intervention, client
    exposure of surgical wound) client will be able weight loss, and serum unable to muster a cellular was able to:
    Subjective data: surgical ↓ to: albumin. immune response to pathogens
    - client verbalizes “indi wound in the Exposure of the and are therefore more Goal met. The
    ko kapangusog kay environment surgical wound to a. Patient remains susceptible to infection. patient was able to
    gasakit ang gin harmful free of infection, be free from
    operahan sakon” microorganisms. as evidenced by - Encourage intake of protein- - This maintains optimal infections brought
    ↓ normal vital signs and calorie-rich foods. nutritional status. by harmful
    Objective data: Natural defense and absence of microorganisms as
    - Facial expression mechanisms of purulent drainage evidenced by
    indicates slight the body are from wounds, - Educate patient of - Friction and running water normal vital signs
    discomfort. inadequate incisions, and importance of frequent hand effectively remove and absence of
    - Limited range of ↓ tubes. washing and teach other microorganisms from hands. purulent drainage
    motion Unable to protect caregivers to wash hands Washing between procedures in her surgical
    - Body weakness the body or before contact with patient and reduces the risk of transmitting wound.
    - Activity intolerance unable to combat between procedures with pathogens from one area of the
    the invading b. Risk for patient. body to another. Goal met. Risk for
    risk factors: organism infection is infection is
    NANDA adequately recognized early recognized early by
    - financial problems Definition: At ↓ to allow for the patient and as a
    increased risk Increased prompt treatment. COLLABORATIVE result, she puts
    Wellness: for being opportunity for - Consult with physician or - Prescription of medicine and more precaution
    - With family support. invaded by invading occupational therapist useful in formulating with her personal
    - Religious pathogenic organism exercises. hygiene and she’s a
    organisms ↓ good compliance
    Risk for infection with her medicine.

    19

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