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NCP

1. The nursing diagnoses, goals, interventions and evaluations are for three patients experiencing fluid volume excess, risk for decreased cardiac output, and ineffective peripheral tissue perfusion. 2. The goals are for the patients to stabilize their fluid volume, display hemodynamic stability, and demonstrate adequate tissue perfusion within 1-2 days. 3. The interventions include monitoring vital signs, administering oxygen, encouraging activity and diet changes, and administering medications to treat the conditions and evaluate responses.

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Levyanne Gsanchez
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95 views6 pages

NCP

1. The nursing diagnoses, goals, interventions and evaluations are for three patients experiencing fluid volume excess, risk for decreased cardiac output, and ineffective peripheral tissue perfusion. 2. The goals are for the patients to stabilize their fluid volume, display hemodynamic stability, and demonstrate adequate tissue perfusion within 1-2 days. 3. The interventions include monitoring vital signs, administering oxygen, encouraging activity and diet changes, and administering medications to treat the conditions and evaluate responses.

Uploaded by

Levyanne Gsanchez
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
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Download as PDF, TXT or read online on Scribd
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NURSING DIAGNOSIS NURSING GOAL NURSING NURSING EVALUATION

INTERVENTIONS
Fluid volume excess After 24-48 hours of nursing 1. Establish rapport After 24-48 hours of nursing
related to compromised intervention, the patient will
 intervention, the patient
regulatory mechanism manifest stabilize
fluid volume 2. Monitor and record vital shall have
manifested
as evidenced by
balance I & O, signs stabilize
fluid volume as
Objective: evidenced by
balance I &

normal VS, stable
weight, and
3. Assess possible risk
free
from signs of
edema. O,
normal VS, stable

• Edema factors
weight, and free
from signs
• alteration and blood
pressure 4. Monitor and record vital of
edema.
• Weight gain signs.
• Oliguria
• Alteration in 5. Note amount/rate of fluid
respiratory pattern intake from all sources
• Changes in mental
status 6. Compare current weight
gain with admission or
previous stated weight

7. Auscultate breath
sounds

8. Record occurrence of
dyspnea

9. Note presence of
edema.

10. Measure abdominal girth


for changes.
11. Evaluate mentation for
confusion and
personality changes.

12. Observe skin mucous


membrane.

13. Change position of client


timely.

14. Review lab data like


BUN, Creatinine, Serum
electrolyte.

15. Restrict sodium and fluid


intake if indicated

16. Record I&O accurately


and calculate fluid
volume balance

17. Weigh client

18. Encourage quiet, restful


atmosphere.
NURSING DIAGNOSIS NURSING GOAL NURSING NURSING EVALUATION
INTERVENTIONS

Risk for Decreased After 12-24 hours of nursing 1. Assess patient’s condition After 12-24 hours of nursing
cardiac output r/t altered interventions the patient will be interventions the patient
afterload (e.g., systemic able to display hemodynamic 2. Monitor and record vital shall have displayed
vascular resistance) stability signs hemodynamic stability

3. Encourage patient to
Subjective Cues:
verbalize concerns
“ Nanghihina pa rin ako”
4. Administer oxygen via
as verbalized by the
face mask or nasal
patient.
cannula

5. Assist with or perform


Objective Cues:
self-care activities for
The patient manifested:
client
-Pallor
-Alteration in Blood 6. Encourage patient to

Pressure change position every two


hours
-Cold clammy skin
7. Encourage patient to do
-Decreased peripheral
relaxation techniques
pulses

-Oliguria
8. Encourage patient to
engage in divertional
activities
9. Provide adequate rest
10. Reinforced low salt and
low fat diet
11. Review laboratory and
diagnostic data

12. Evaluate client reports


and evidence of fatigue
intolerance for activity,
sudden or progressive
weight gain, telling of
extremities and shortness
of breath

13. Minister medications as


appropriate and monitor
cardiac responses
NURSING DIAGNOSIS NURSING GOAL NURSING NURSING EVALUATION
INTERVENTIONS
Ineffective peripheral tissue After 1- 2 days of nursing 1. Assessed pt.’s After 1- 2 days of nursing
perfusion related to interventions, the patient will interventions, the patient
condition.
Diabetes Mellitus and be able to demonstrate shall have demonstrated
Hypertension adequate tissue perfusion 2. Monitored and adequate tissue perfusion
as evidenced by palpable as evidenced by palpable
recorded vital signs.
Objective Cues: peripheral pulses, warm and peripheral pulses, warm and
dry skin, adequate urinary 3. Noted color and dry skin, adequate urinary
Fatigue output, and the absence of output, and the absence of
temperature of the
respiratory distress. respiratory distress.
Pallor skin.
4. Monitored peripheral
Oliguria
pulse.
Decrease Peripheral Pulses
5. Measure Capillary
Alteration in skin Refill
characteristics
6. Current situation or
Edema on Lower presence of
Extremities
conditions
Alteration in motor function 7. Review Laboratory
studies
8. Provided a warmth
environment.
9. Monitored urine
output.
10. Administer
medications as
ordered such as
antiplatelet agents
thrombolytics
antibiotics and
beyond

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