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    NCP Hmole

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    merii
    This nursing care plan summarizes interventions for a patient experiencing a fluid volume deficit due to early pregnancy complications. The patient reported vaginal bleeding and morning vomiting. Tests revealed elevated human chorionic gonadotropin levels indicating pregnancy and multiple cysts in the uterus. Objective findings included anemia. The nursing diagnosis was fluid volume deficit related to early pregnancy. The plan's objectives were to restore adequate fluid balance through interventions like IV fluids, monitoring vitals and output, encouraging fluid and rest. The plan was evaluated through stable vitals, moist skin and adequate urine output.

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    NCP Hmole

    Uploaded by

    merii
    1K views5 pages
    This nursing care plan summarizes interventions for a patient experiencing a fluid volume deficit due to early pregnancy complications. The patient reported vaginal bleeding and morning vomiting. Tests revealed elevated human chorionic gonadotropin levels indicating pregnancy and multiple cysts in the uterus. Objective findings included anemia. The nursing diagnosis was fluid volume deficit related to early pregnancy. The plan's objectives were to restore adequate fluid balance through interventions like IV fluids, monitoring vitals and output, encouraging fluid and rest. The plan was evaluated through stable vitals, moist skin and adequate urine output.

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    This nursing care plan summarizes interventions for a patient experiencing a fluid volume deficit due to early pregnancy complications. The patient reported vaginal bleeding and morning vomiting. Tests revealed elevated human chorionic gonadotropin levels indicating pregnancy and multiple cysts in the uterus. Objective findings included anemia. The nursing diagnosis was fluid volume deficit related to early pregnancy. The plan's objectives were to restore adequate fluid balance through interventions like IV fluids, monitoring vitals and output, encouraging fluid and rest. The plan was evaluated through stable vitals, moist skin and adequate urine output.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Download as docx, pdf, or txt
    1K views5 pages

    NCP Hmole

    Uploaded by

    merii
    This nursing care plan summarizes interventions for a patient experiencing a fluid volume deficit due to early pregnancy complications. The patient reported vaginal bleeding and morning vomiting. Tests revealed elevated human chorionic gonadotropin levels indicating pregnancy and multiple cysts in the uterus. Objective findings included anemia. The nursing diagnosis was fluid volume deficit related to early pregnancy. The plan's objectives were to restore adequate fluid balance through interventions like IV fluids, monitoring vitals and output, encouraging fluid and rest. The plan was evaluated through stable vitals, moist skin and adequate urine output.

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    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Download as docx, pdf, or txt
    of 5

    COLLEGE OF NURSING

    Silliman University
    Dumaguete City

    NURSING CARE PLAN

    CUES / EVIDENCES NURSING DIAGNOSIS OBJECTIVES INTERVENTIONS RATIONALE EVALUATION


    Subjective Data: Fluid volume deficit r/t After my two-day duty, the Independent:
    elevated levels of human patient will display adequate  Assess skin turgor  This is an indicator of
    Patient verbalized, “I suffered Chorionic Gonadotropin fluid balance as evidenced and moisture of hydration
    from vaginal bleeding that (hCG) from the proliferating by: mucous membranes status/degree of
    varies from dark brown trophoblasts  Stable vital signs deficit
    spotting for 1 day, and 3 days  Moist mucous  Monitor Vital Signs.  To have a baseline
    ago, I also experienced membranes Evaluate peripheral data, reflects
    excessive vomiting in the  Skin turgor less than pulses, capillary refill adequacy of
    morning.” 1 second circulating volume
     Capillary refill of less  Monitor I&O; include  Decreasing renal
    Objective Data: than 2 seconds all output sources output and
    > Vital Signs: T - 36.5 degrees  Adequate urine concentration of
    Celsius output urine suggest
    P - 86 bpm developing
    R - 20 cpm dehydration and
    BP - 110/70 mmHg need for fluid
     Urinalysis test for replacement
    hCG revealed  Weigh patient daily  Sensitive
    positive measurement of
     UTz revealed fluctuations in fluid
    multiple small cystic balance
    structures, with  Observe for bleeding  Early identification of
    negative for fetal tendencies; Note the problems (which may
    parts and fetal amount, lochia/color occur as a result of
    heartbeat. of the vaginal cancer), allows for
     Hemoglobin of 86 g/L discharge prompt intervention
     Hematocrit of 0.25  Encourage increase  To compensate with
     RBC of 2.87 fluid intake as the fluid volume
    tolerated deficit problem
     Encourage ice chips  For the vomiting
    on mouth episodes
     Encourage rest  Prevent unnecessary
    energy expenditure
    related to vomiting
    (as may trigger) and
    bleeding
     Encourage the  To help the patient
    patient to have a develop new mature
    high protein, folic red blood cells to
    acid and carotene prevent further
    diet anemia due to blood
    loss

    Dependent:  To be started with


     Administer the dilation of the
    intravenous oxytocin cervix and continued
    and ordered by the postoperatively to
    physician reduce likelihood of
    hemorrhage.
    Consideration of
    using other
    uterotonic
    formulations such as
    Methergine or
    Hemabate is also
    accepted.

     During surgery, this


     Assisted Ventilation can happen due to
    and Monitoring for trophoblastic
    Respiratory distress embolization, high-
    output congestive
    heart failure caused
    by anemia.
    Ventilation and
    monitoring should be
    done during such
    situation

     Increased HCG
     Monitor HCG for 1 results to
    year Choriocarcinoma

    Collaborative:  To help patient


     Collaborate with the develop new mature
    Dietary Department red blood cells to
    that rotein, folic acid, prevent further
    B12-rich food should anemia due to blood
    be served loss
    CUES / EVIDENCES NURSING DIAGNOSIS OBJECTIVES INTERVENTIONS RATIONALE EVALUATION
    CASE SCENARIO:

    S> Mrs. Smith, a 35 year old, married complained of vaginal bleeding that varies from dark brown spotting for 1 day duration. 3 days PTA, Mrs. Smith experienced excessive vomiting that occurs
    in the morning.

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