NCP

Download as docx, pdf, or txt
Download as docx, pdf, or txt
You are on page 1of 9

ASSESSMENT NURSING PLANNING INTERVENTIONS RATIONALE EVALUATION

DIAGNOSIS

Objective: Fluid volume Short term Independent Short term


 Concentrated deficit related to After effective Goal met:
urine Inadequate fluid nursing  Encourage the  Oral fluid After effective
 Decreased urine intake interventions patient to drink replacement is nursing
output 25mL/hr) the client will be adequate indicated for mild interventions the
 Decreased skin able to: amount of fluid. fluid deficit. client was able to:
turgor
 Verbalize  Educate patient  Enough knowledge  Verbalized
VS: awareness of about possible aids the patient to awareness of
BP: 90/70 causative cause and effect take part in his or causative
HR: 111 beats/min factors and of fluid losses or her plan of care. factors and
behaviors decreased fluid behaviors
essential to intake. essential to
correct fluid correct fluid
deficit.  Monitor for the  Early intervention deficit.
existence of can decrease the
 Explain factors causing occurrence and  Identified
measures deficient fluid severity of measures that
that can be volume  complications from can be taken to
taken to deficient fluid treat or prevent
treat or volume.  fluid volume
prevent fluid loss.
volume loss.
 Monitor and  Decrease in Long term:
Long term document vital circulating blood vo Goal met:
After effective signs especially lume can cause After
nursing BP and HR. hypotension and effectivenursing
intervention the tachycardia. interventions the
client will be Alteration in HR is a client was able to:
able to exhibit: compensatory
mechanism to
 Normovolem maintain cardiac  Exhibit
ic as output. normovolemic as
evidenced by evidenced by
systolic BP  Assess skin  Signs of systolic BP of
greater than turgor and oral dehydration are 110
90 mm HG mucous detected through
(or patient’s membranes for the  Exhibit HR of 89
baseline), signs of skin. Longitudinal
dehydration. furrows may be
 HR 60 to 100 noted along the  Exhibit urine
beats/min tongue output of 60
mL/hr

 Urine output
greater than  A normal urine  Exhibit normal
30 mL/hr  Assess color and output is skin turgor
amount of urine. considered normal
not less than
 Normal skin 30ml/hour.
turgor Concentrated urine
denotes fluid
deficit.
 Auscultate and  Cardiac alterations
document heart like dysrhythmias
sounds; note may reflect
rate, rhythm or hypovolemia
other abnormal and/or electrolyte
findings. imbalance,
commonly
hypocalcemia

Collaborative

 Monitor fluid  Most fluid comes


status in relation into the body
to dietary intake. through drinking
and water in food.
Verifying if the
patient is on a fluid
restraint is
necessary.

DRUG MODE OF INDICATION/ ADVERSE EFFECTS NURSING


ACTION CONTRAINDICATION RESPONSIBILITIES

NAME: Oxytocin Sterile, INDICATIONS:  Hypertension  Continuously


nonpyrogenic  Increased HR monitor fetal and
PHARMACOLOGIC
solution for fluid  To induce or  Nausea maternal HR & BP
CLASS: Posterior stimulate labor  Vomiting and ECG.
Pituitary Hormone and electrolyte
 Anoxia Discontinue infusion
replenishment CONTRAINDICATIONS:  Asphyxia if uterine
THERAPEUTIC that contains no hyperactivity occurs
CLASS: Uterine antimicrobial  Patients
active agent agents. hypersensitive to  Monitor patient
drug extremity closely
ROUTE/DOSAGE: during first and
IV drip, 10 IU in 1  Cephalopelvic second stages of
litre, 10cc/hr disproportion is labor because of risk
present of cervical
laceration, uterine
 When delivery rupture and
requires conversion maternal and fetal
as in transverse line death

 Assess fluid intake


and output, watch
for a/a of water
intoxication
NAME: Stimulates INDICATIONS:  Drowsiness  Assess patient for
Metocloropamide motility of upper  Extrapyramidal nausea, vomiting,
GI tract, increases  Treatment and reaction abdominal
PHARMACOLOGIC lower esophageal prevention of  Restlessness distention, and
CLASS: Dopamine sphincter tone, postoperative nausea  Constipation bowel sounds before
antagonists and blocks and vomiting when  Diarrhea and after
dopamine nasogastric  Gynecomastia administration.
THERAPEUTIC receptors at the suctioning is  Hypertension
CLASS: chemoreceptor undesirable.  Agranulocytosis  Assess patient signs
antiemesis trigger zone. of depression
Decreased CONTRAINDICATIONS: periodically
ROUTE/DOSAGE: nausea and throughout therapy.
 Patients
IV, 1 amp vomiting.
hypersensitive to  Monitor patient for
drug dizziness, headache,
or nervousness after
 History of seizure medication is
disorder stopped; these may
indicate withdrawal.
 Parkinson’s disease

 Possible GI
obstruction
NAME: Ranitidine Specific, rapidly INDICATIONS:  Headache  Advice patient to
acting histamine  Abdominal report all adverse
PHARMACOLOGIC  This drug is known to discomfort/pain reactions, especially
H2-antagonist. It
CLASS: H2-receptor increase prolactin  Constipation abdominal pain,
antagonists inhibits basal and levels.  Nausea blood in stool or
stimulated
 Vomiting emesis, coffee
THERAPEUTIC secretion of CONTRAINDICATIONS:
 Acute pancreatitis ground emesis, or
CLASS: Antiulcer gastric acid, and  Diarrhea black, tarry stools.
drugs  Patients
is known to
hypersensitive to  Hypotension
increase prolactin drug  Chest pain 
ROUTE/DOSAGE:
levels.  Arrhythmia
IV, 1 amp
 Contraindicated in  Insomnia
patients with acute
porphyria.

 Use cautiously in
patients with hepatic
dysfunction and
adjust dosage in
patients with
impaired renal
function.
NAME: Paracetamol Inhibits the INDICATIONS:
synthesis of  Rash  Assess fever; note
PHARMACOLOGIC prostaglandins that  This drug is used to  Itching or swelling presence of
CLASS: may serve as treat mild to (especially of the associated signs
mediators of pain moderate pain face/tongue/throat) (diaphoresis,
THERAPEUTIC and fever,primarily (from headaches,
in the CNS. Has no  Severe dizziness tachycardia, and
CLASS: Antipyretics, menstrual  Trouble breathing malaise)
significant anti-
nonopiod periods, toothaches,  Leukopenia
inflammatory
analgwsics properties or GI backaches, osteoarth  Assess type of pain,
toxicity. ritis, or cold/flu aches location, and
ROUTE/DOSAGE: and pains) and to intensity prior to and
IV, 1g every 8hrs x 6 reduce fever. 30-60min following
doses administration
CONTRAINDICATIONS:

 Patients
hypersensitive to
drug
 Use cautiously in
patients with hepatic
disease/renal disease

NAME: Cefazolin Prophylaxis INDICATIONS:


against infection
PHARMACOLOGIC  Cefazolin is  Confusion  Watch for seizures;
CLASS: an antibiotic used to  Diarrhea notify physician
Cephalosporin treat a wide variety  Drowsiness immediately if
of bacterial infections  Eosinophilia patient develops or
THERAPEUTIC . It may also be used  Fainting increases seizure
CLASS: Antibiotic before and during activity.
certain surgeries to
ROUTE/DOSAGE: help  Gas  Assess muscle aches
IV, 2g prevent infection.  Headache and joint pain
This medication is  Heartburn (arthralgia) that may
known as a  Hives be caused by serum
cephalosporin  Increased sickness. 
antibiotic. It works by transaminases
stopping the growth  Lightheadedness  Instruct patient to
of bacteria.  hypotension notify physician of
 Leukopenia signs of
CONTRAINDICATIONS:  Neutropenia superinfection,
 Nausea and including black, furry
 Dose must be overgrowth on
vomiting
adjusted in severe
 Oral thrush tongue, vaginal
renal insufficiency
 Phlebitis itching or discharge,
(high doses may and loose or foul-
 Pseudomembranou
causeCNS toxicity; smelling stools.
s colitis
superinfections and
 Rectal itching
may occur with
 Seizure
prolonged use or
repeated therapy  Skin rash or itching
 Stomach
 Use with caution in cramps/pain
patients with seizure  Thrombocytosis
disorder (high levels  Tiredness
are associated with  Vaginal itching
increased risk of or discharge
seizures)  Weakness
 White patches or
 Use with caution in sores inside
renal impairment the mouth or on
the lips

You might also like