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    Name: Grace AGE: 28 Gender: Female Assessment Nursing Diagnosis Objectives Nursing Intervention Rationale Evaluation Subjective: General

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    Rainier Ibarreta
    2. Referral to obstetrician- 1. Monitor the patient for adverse gynecologist for further effects of medications. evaluation and management. 2. Monitor vital signs, intake and output, daily weights, and skin turgor. 3. Provide oral care every 2 hours. 4. Encourage fluid intake of at least 2000 ml/day. 5. Provide comfort measures as needed. 6. Monitor the severity of vomiting and hydration status. 7. Report changes in condition to the primary nurse. EVALUATION: The patient's condition improved as evidenced by: - Decreased frequency

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    Name: Grace AGE: 28 Gender: Female Assessment Nursing Diagnosis Objectives Nursing Intervention Rationale Evaluation Subjective: General

    Uploaded by

    Rainier Ibarreta
    56 views2 pages
    2. Referral to obstetrician- 1. Monitor the patient for adverse gynecologist for further effects of medications. evaluation and management. 2. Monitor vital signs, intake and output, daily weights, and skin turgor. 3. Provide oral care every 2 hours. 4. Encourage fluid intake of at least 2000 ml/day. 5. Provide comfort measures as needed. 6. Monitor the severity of vomiting and hydration status. 7. Report changes in condition to the primary nurse. EVALUATION: The patient's condition improved as evidenced by: - Decreased frequency

    Original Description:

    Original Title

    NCP Electrolyte imbalance

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    2. Referral to obstetrician- 1. Monitor the patient for adverse gynecologist for further effects of medications. evaluation and management. 2. Monitor vital signs, intake and output, daily weights, and skin turgor. 3. Provide oral care every 2 hours. 4. Encourage fluid intake of at least 2000 ml/day. 5. Provide comfort measures as needed. 6. Monitor the severity of vomiting and hydration status. 7. Report changes in condition to the primary nurse. EVALUATION: The patient's condition improved as evidenced by: - Decreased frequency

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Download as docx, pdf, or txt
    56 views2 pages

    Name: Grace AGE: 28 Gender: Female Assessment Nursing Diagnosis Objectives Nursing Intervention Rationale Evaluation Subjective: General

    Uploaded by

    Rainier Ibarreta
    2. Referral to obstetrician- 1. Monitor the patient for adverse gynecologist for further effects of medications. evaluation and management. 2. Monitor vital signs, intake and output, daily weights, and skin turgor. 3. Provide oral care every 2 hours. 4. Encourage fluid intake of at least 2000 ml/day. 5. Provide comfort measures as needed. 6. Monitor the severity of vomiting and hydration status. 7. Report changes in condition to the primary nurse. EVALUATION: The patient's condition improved as evidenced by: - Decreased frequency

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Download as docx, pdf, or txt
    of 2

    NAME: GRACE

    AGE: 28

    GENDER: FEMALE

    ASSESSMENT NURSING DIAGNOSIS OBJECTIVES NURSING INTERVENTION RATIONALE EVALUATION

    SUBJECTIVE: General Independent: Independent:


     Deficient fluid volume related  Be free of complications 1. Establish rapport 1. To gain the patient trust to be  Goal met; the
    “nagsusuka ako ng 10 beses ng to increase in HCG as evidence resulting from electrolyte 2. Assess the vital signs of the cooperative. patient decrease
    isang araw” as verbalized by the by” vomiting 10 times within imbalance. patient 2. To have a baseline data the severity of
    patient. 24 hours”.  To facilitate the fluid 3. Assessing the patient with the Vomiting 10 times
    imbalance 3. Determine causes of nausea. causes of nausea will guide the a day to 4
     The potassium level will be choice of interventions to be times/day.
    on the normal level. 4. Record the patient’s hydration used. Treatment may not be
    status, daily weights, BP, intake needed if the stimulus is
    OBJECTIVE: and output, and assessing skin eliminated.
    Specific turgor. 4. Nausea is usually correlated
     BP: 90/60 mmHg  After 2 – 3 days the with vomiting that can change a
    patient will able to reduce 5. Educate and assist patient patient’s hydration status
     PR: 106 beats/min Severity of Vomiting 10 about oral hygiene. because of fluid loss.
    times a day to 4times/day. 5. This is associated
     Dry mucous membrane 6. Eliminate strong odors from with anorexia and excessive
    the surrounding (e.g., salivation. Oral hygiene helps
     Potassium 2.5 mmol/L perfumes, dressings, emesis) alleviate the condition and
    facilitates comfort.
    7. Educate the patient about the 6. Strong and noxious odors can
    importance of changing contribute to nausea.
    positions slowly and calmly.
    7. Abrupt or gross movements may
    aggravate the condition.
    Dependent:
    Dependent: 1. It acts on the chemoreceptor
    1. Administer Diclegis 10mg per trigger zone to reduce nausea
    tablet, 2 tablets at bedtime. and vomiting.

    Collaborative:
    Collaborative: 1. A series of tests may be used
    1. Assist the patient in diagnostic to determine the contributing
    testing preparation. factor (e.g., upper
    gastrointestinal tract study,
    abdominal computed
    tomography scan,

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