Nursing Diagnosis#1( Deficient fluid volume)
9/2015 acs; reviewed 8/2016 acs 1
Assessment Data
Nursing Diagnosis
Expected
Outcomes
Nursing Interventions
Rationale with Sources
Evaluation
Relevant objective and
subjective findings that
substantiate Nursing
Diagnosis
Relates to assessment data,
includes related precipitating
factors, prioritized by Maslow’s
hierarchy
1 Short Term Goal, 1
Long Term Goal;
appropriate to
diagnosis, patient
centered, measurable,
contains a time frame
for attaining
Identifies who, what, where, when, and
how; Independent nursing actions or
collaborative practice, includes meds,
labs, dx testing. (NOT limited to 4)
States reason why intervention can be expected to accomplish
objective; provide source used example textbook, nursing
article, etc…
This derives from
outcomes. Includes
nursing evaluative
measures, client
responses, follow-up
findings, achievement
of outcome or need
for modification
SUBJECTIVE:
Pt stated: I was told
being pregnant 8 weeks
ago, I have been having
heavy bleeding since
last night now I feel
week.
OBJECTIVE:
-delayed capillary
refill
-tachycardia
-lethargy
-hypotension
DIAGNOSIS:
Deficient fluid volume
RELATED TO:
Excessive blood
loss
AS EVIDENCED BY:
Decrease in the red
blood cell count
with Hgb 10.5 g/dl
STG: Pt will
maintain
functional level
of fluid volume
as well as stable
vital signs by the
end of the shift
LTG
Pt will eat and
take appropriate
supplement
necessary in
order maintain
RBC in the
normal range
1) Assess and record
the type and quantity of
the bleeding. Count and
weigh perineal pads
possible Save blood
clot to be evaluated by
a physician
2)Replace the fluid lost and
blood product through blood
transfusion.
3)Monitor vital signs. Check
for capillary refill and observe
nails beds and mucous
4) Place patient in lateral
position and strict bed rest
1)The amount of blood loss and the
presence of blood clots will help to
determine the appropriate replacement
need of the patient. (nurseslab.com)
2) replace the lost blood in the body that has
been lost because of the hemorrhage
(Nurseslab.com)
3)increased heart rate, low blood pressure,
cyanosis, delayed capillary refill
indicates hypovolemia and impending shock.
Decrease fluid volume of 30-50% will reflect
changes in the blood pressure.
(Nurseslab.com)
4)This position helps relieve pressure
on the vena cava and helps reduce
bleeding. Bed rest is required to limit
blood loss and help with pain
management
(academynursing.com)
STG: Pt
demonstrated
improvement
in fluid
balance and
vital signs
throughout my
shift
LTG:
Pt demonstrate
understanding
about eating
appropriate
nutrients to
maintain normal
RBC range
Nursing Diagnosis#1( Deficient fluid volume)
Nursing Diagnosis #2 ( ineffective pain management )
Nursing Diagnosis
Expected Outcomes
Nursing
Interventions
Rationale with Sources
Evaluation
Relates to assessment data,
includes related
precipitating factors,
prioritized by Maslow’s
hierarchy
Overall outcomes and goals. 1
Short Term Goal, 1 Long Term
Goal; appropriate to diagnosis,
patient centered, measurable,
contains a time frame for
attaining
Identifies who, what, where,
when, and how; Independent
nursing actions or collaborative
practice, includes meds, labs,
dx testing. (NOT limited to 4)
States reason why intervention can be expected
to accomplish objective; provide source used
example textbook, nursing article, etc…
This derives from outcomes.
Includes nursing evaluative
measures, client responses,
follow-up findings, achievement
of outcome or need for
modification
DIAGNOSIS:
Infective pain
management
RELATED TO:
STG
Pt will repot decrease
of pain by the end of
the shift
1)asses psychological
causes of pain
2)Perform pain
assessment by
identifying the type,
location and severity
1Emergency situations may
precipitate fear, anxiety which
can raise perception of pain
and
discomfort.(Nurseslab.com)
STG:
Pt reports pain of 2/10