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NCP 1

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  NCP PROPER NURSING PROBLEM EXPLANATION OF THE PROBLEM OBJECTIVES NURSING INTERVENTIONS RATIONALE OUTCOME CRITERIA EVALUATION Subjective: “Kanina pa nga may tumulo na ganyan, nung gabi wla naman lumabas ngayon ngayon lang. Objective: Midline incision approximately 6 inch in length, whitish to reddish boarders, center or the wound is intermittently draining a foul smelling greenish-yellowish discharge, with fully soaked dressing. Linens and clothes are fully soaked. With Open drainage via NGT draining a coffee ground like drain approximately 50 ml. Decreased skin turgor, pale and crack lips, dry mucous membranes with dry skin. With distended abdomen, emaciated. Ectomorph body type. Currently on NPO Stomach cancer, also known as gastric cancer, is the accumulation of an abnormal (malignant, cancerous) group of cells that form a tumor in any part of the stomach - in most cases, it refers to cancer that starts off in the mucus-producing cells on the lining of the inside of the stomach. The patient then went for surgery on September to confirm the disease but they are only able to insert a PEG. The wound stretched and there was a slight opening in the center, where the leak is coming from. LTO: After 72 hours of nursing intervention the client will be able to display adequate fluid balance as evidenced by stable vital signs and moist mucous membrane. STO: After 8 hours of nursing interventions, the client will be able to have moist mucous membrane. After 8 hours of nursing intervention, the client will not develop dryness of skin or cracked lips. Monitor I&O and specific gravity; include all output sources. Monitor daily weight for sudden decreases, especially in the presence of decreasing urine output or active fluid loss. Weigh clinet on same scale with the same clothing at the same time preferably before breakfast. Monitor vital signs. Evaluate peripheral pulses, capillary refill. Assess skin turgor and moisture of mucous membranes. Note reports of thirst. Monitor serum and Continued negative fluid balance, decreasing renal output and concentration of urine suggest developing dehydration and need for increased fluid replacement. Body weight changes reflect changes in body fluid volume. Clinically it is extremely important to get an accurate body weight of client with fluid imbalance (Metheny.1996) Reflects adequacy of circulating volume. Indirect indicators of hydration status/degree of deficit. These are all measures LTO Fully met: After 72 hours of nursing intervention the client will be able to display adequate fluid balance as evidenced by stable vital signs and moist mucous membrane Partially met: After 72 hours of nursing intervention the client will be able to display adequate fluid balance as evidenced by moist mucous membrane only. Not met: After 72 hours of nursing intervention the client will be able not be able to display adequate fluid balance. STO: Fully met: After 8 hours of nursing interventions, the client will be able  NCP PROPER orders With VS of BP= 90/60 PR=75 RR=22 Temp=37.2 Nursing Diagnosis: Risk for fluid volume deficit related to active leakage of fluid from the abdominal incision site. urine osmolality, serum sodium, BUN creatinine, and haematocrit for elevations Document fluid volume status at least every 8 hours or more frequently when client’s condition is unstable Promote oral intake if not contraindicated. Dab the patients lips with wet cotton balls. Maintain patency of IV, maintain appropriate IV infusion flow rate Position client flat with legs elevated when hypotensive. Once NPO orders are eliminated, encouraged to increase fluid intake up to 3000ml if not contraindicated. of concentration and will be elevated with decreased intravascular volume. Documentation facilitates the identification of trends in fluid balance by indicating status of condition and response to therapy. If contraindicated, this is an alternative to satisfy the thirst the patient have. Isotonic fluids allow replacement of intravascular volume. Provides venous return thus contributing to the maintenance of cardiac output. Promotes replacement of intravascular or intracellular volume as necessary. to have moist mucous membrane. Not met: After 8 hours of nursing interventions, the client will not be able to have moist mucous membranes Fully met: After 8 hours of nursing intervention, the client will not develop dryness of skin or cracked lips. Partially met: After 8 hours of nursing intervention, the client will no still develop dryness of skin or cracked lips. Not met: After 8 hours of nursing intervention, there is no changes in the clients condition.  NCP PROPER

SSRN-id2091102

Jul 23, 2017
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