Assessment

Diagnosis

Planning Fluid Balance: Maintain fluid volume at functional level Normal urinary output of 50-80ml per hour with normal Specific Gravity of Stable vital signs Moist mucous membranes Good Skin Turgor and prompt capillary refill

Intervention Monitoring Vital Signs Observation for Temperature changes

Rationale Noting the Degree of Blood Pressure changing A Fever increases metabolism which increases fluid loss

Evaluation Patient must Maintain adequate fluid volume as evidenced by normal vital signs Moist Mucous membranes

Tongue- Smaller, Fluid Volume Deficit furrowed, thick paste-like layer on surface. Skin- Pale and Cool to touch Face- Sunken eyes in the advanced stage Pulse- Rapid but weakTachycardia Mental statusDisorientated, confused, hallucinations Physical Activity- Weak, fatigued Respiration- Tachypnoea, shallow Elimination- Abdominal Cramping, constipation, dark urine.

Patient Ability to Swallow Impaired Gag/Swallow, Adequate intake and nausea, oral discomfort Output with normal affect the ability to replaceSpecific Gravity fluids orally Relieves thirst and discomfort of dry mucous membranes Tissues susceptible to breakdown because of increased cellular fragility Skin and mucous membranes are dry with decreased elasticity. Daily bathing may increase dryness

Knowledge: Verbalise understanding of causative factors and 24 hr Schedule of foods purpose of interventions with high fluid content Demonstrate behaviour to monitor and correct when Turn Frequently, Massage appropriate Skin and protect bony areas Provide skin and mouth care, bathe every other day using mild soap

Patient may have altered Provide safety such as sidemental thought process rails, bed in low position which may increase the and frequent observations risk of injury Too rapid correction in Monitor for a sudden fluid balance may increase in blood pressure compromise cardiopulmonary system

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Assessment

Diagnosis

Planning

Intervention Monitor daily weight

Rationale For sudden decreases especially when urine output is low, but must use the same scale, same time, and similar clothing before breakfast. Small Frequent doses

Evaluation

Provide oral replacement therapy Provide patient with 500ml water, juice(noncaffeinated) over 8 hours

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Assessment

Diagnosis

Planning Short Term: After 24 hours

Intervention

Rationale

Evaluation

Temperature > 37.5 Pyrexia, Hyperthermia degrees Flushed Skin Warm to touch Person experiences the chills Increased Respiration and laboured breathing Tachycardia Sweating

Establish the nurse patient Gaining the patients trust Observe Temperature to relationship find the body temperature Obtain the baseline data is in normal range Obtain Vital Signs Monitor heat and fluid loss No Dizziness experienced Monitor absence or presence of sweating Minimize shivering Patient has an improvement of sleep Wrap Extremities in bath patterns towel Lowers Body Temperature Provide outer body wet wipe every 15min Apply local ice packs in axilla Instruct client to rest Reduce Body Temperature in areas of High blood flow Reduce metabolic demands to prevent fluid loss To support circulatory blood volume and tissue perfusion Promote heat loss through conduction and convection

Increase oral fluid intake and administer replacement

To restore normal Body Reduce external coverings Temperature and to such as clothing and keep determine the the bed dry effectiveness of the interventions done. Administer antipyreticsreassess temperature every 15 minutes

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Assessment Find out food intake Social Interaction Weigh client and assess posture: Body Mass Index and Ideal Body Weight correlations, Stooped posture Observe poor nutrition: Hair loss or thinning, dry scaling skin Palpate muscles and extremities; poor muscle tone, thin and wasted

Diagnosis Imbalanced Nutrition, less than body requirements- decreased ability to ingest food

Planning Goals: Gain Weight Consume adequate nourishment No signs of malnutrition

Interventions Nutritional Counselling Care plan facilitated by medical practitioner, psychologist, client and dietician. Individual meal plans

Rationale

Evaluation Food Diary- We can see if patient is choosing the correct foods at relevant times, see if he/she understood the education Appearance- Hair Better condition, weight gain, improved physical appearance, healthy looking and sounding Appetite and energy level: increased with social level which also increases self esteem

Aetiologies: Depressed Mood Loss of Appetite Energy level too low to meet own needs Ideas of self-destruction Lack of interest in food

Outcomes: Progressive gaining of weight and a progressive nutritional status improvement. To remain risk free of infections due to undernourishment. Verbalise understanding of nutritional requirements and identify strategies to incorporate into daily diet after discharge.

Multidisciplinary approach, continuity of care

Encourages client to eat Educate on food pyramid by including favourite meals Encourage client to eat small meals Encourage fibre intake Encourage to eat with others- social Recommendations for food selections-to improve understanding Frequent small meals reduce the risk of being anorexic Defers Constipation and enhances appetite Enhances Socialisation

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Assessment

Diagnosis

Planning

Intervention Determine degree of immobility in relation to functional level Assist in repositioning client at a regular schedule as ordered by a physician Safety Measures

Rationale

Evaluation Maintained Position and function of skin integrity, no foot drop or pressure sores. Significant other will be able to demonstrate techniques that will enable repositioning

General Body Weakness Impaired Physical Mobility Maintain position and Inability to perform gross function of skin integrity motor skills as evidenced by absence Difficulty in performing of pressure sores or foot Activities of daily living drop Safe positioning Encourage independence

Prevents complications Encourage to be involved in decision making Side rails, pillows to Involve significant other in prevent injury or care and assist them in complications ways to learn Enhances commitment to Assist with exercises with plan optimizing outcomes working limbs Impart health Teaching Increase independence in activities of daily living Apply any ordered brace before mobilising client Obtain any assistive devices for activity Assess Skin Integrity Increase the use of the mobile limb Providing unnecessary assistance may promote dependence and a loss of mobility Brace support and stabilising body part for activity, and increases the ease of mobility For colour changes, redness, swelling, warmth, pain or infection

The client will have gained a degree of independence which increases self respect and self esteem.

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Assessment

Diagnosis

Planning

Intervention

Rationale To gain trust To monitor for any improvements To protect patient from heat loss Promote heat

Evaluation Short Term: Clients body temperature reached normal functioning range Long Term: Client was able to verbalise ways of treating And preventing hypothermia.

Reduction in body Hypothermia temperature below normal Range, below 35 degrees Celsius Shivering Skin cool to touch Pallor Slow Capillary refill Hypertension Tachycardia

Short term: Establish Nurse Patient Raise the core Body Relationship Temperature Lower risk of developing anMonitor Vital Signs abnormal heart rhythm Wet clothing to removed Long Term: and replaced with dry Patient will verbalise blankets . behaviours to monitor and promote normal body Administer fluids during temperature regulation rewarming

To prevent hypovolemic Provide well balanced high shock calorie diet To replenish any integral Perform a range of light lost nutrients, to replenish motion exercises, glycogen and nutritional reposition client, breathing balance exercises To increase mobility and Promote Skin Integrity by warm the patient repositioning, applying lotion and avoid any direct Impaired circulation can contact with a heating result in severe tissue appliance damage Provide patient airway with To Provide heat and to humidified oxygen when prevent dehydration used

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Assessment Bedridden Risk for Infection Impaired Skin Integrity Impaired Nutritional deficit Impaired ability to turn side to side Impaired ability to move from supine to sitting position General Weakness

Diagnosis Impaired Bed MobilityConfinement

Planning

Intervention

Rationale

Evaluation

Maintain or increase Determine Diagnosis that Identify Causative Factors Verbalise understanding of strength and endurance of contributed to the the risk factors associated upper and lower immobility with immobility. extremities To assess the extent the Determine functional level client can manage by Ability to demonstrate safe Will not develop his/her self. repositioning and safe complications from hygiene and treatment immobility Reposition client in bed Assesses signs of skin options according to instructions or breakdown Demonstrate use of patients request Maintenance of Skin adaptive devices for Integrity is fully understood mobility Monitor vital Signs An Increase in Vital signs and can be demonstrated may be significant of an Verbalise understanding of infection the situation and can participate in decision Monitor input and Output Adequate hydration making improves wound healing. Decreased urine output is a sign of dehydration. Monitor Nutritional Intake Altered nutrition can prevent wound healing and put pt at risk for further Assist with activities such skin breakdown as hygiene toileting and feeding To promote optimal level of care Involve a clients significant other in determining To promote commitment to activity schedule plan and maximise outcomes

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NRSE1000 Comprehensive Nursing 2011 Stephanie McAlinden 0609356T Nursing Care Plans 1. Care of a Dehydrated Patient 2. Care of a Patient with a Fever 3. Care of an Undernourished Patient 4. Care of a Paraplegic, Quadriplegic Patients 5. Care of a Hypothermic Patient 6. Care of a Confined Patient

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