GRADE:
NURSING CARE PLAN
Name of Patient: GONZALES,
Age: 24
Sex: F
Religion: ROMAN CATHOLIC
Date of Admission:
Chief Complaint: VAGINAL SPOTTING
Attending Physician: DR. FRANCO
Civil Status: SINGLE
DATE &
CUES
TIME
Septem Subjective: “ Luya kaayo
ber 9akong lawas” as
10,
verbalized by the patient.
2019
Objective:
>Restlessness
>Unable to rise on bed
>VS
T: 35.9 degrees Celsius
P: 88 bpm
R:15 cpm
BP: 100/60
NURSING DIAGNOSIS
Risk for Fluid Volume
Deficiency related to Vaginal
Spotting
SCIENTIFIC BASIS
Fluid volume deficit descrbes
the loss of extracellular fluid
from the body. I constitutes
about 20% of our body weight
and includes blood plasma,
lymph, spinal cord fluid, and
the fluid between cells. It can
also harm or affect when a
woman is pregnant due to
dehydration. One of its sign
that indicates preterm labor is
the vaginal spotting. This is the
most common cause of
abnormal vaginal bleeding
during a woman’s childbearing
years. Up to 10% of women
may experience excessive
bleeding at one time or
another
GOAL & OBJECTIVES
NURSING INTERVENTION
At the end of 16 hours
nursing care, patient
will be able to:
> Demonstrate
improvement fluid
balance as evidence by
stable vital sign and
good skin turgor.
> Maintain fluid
volume of a functional
level as evidence by
individually adequate
urinary output with
normal specific gravity,
moist mucous
membranes, and
prompt capillary refill.
> Demonstrate
behaviors or lifestyle
changes to prevent
development of fluid
volume deficit.
Independent:
1. monitor vital sign,
compare with normal or
previous readings
2. Note patient’s individual
physiological response to
bleeding such as weakness
and restlessness
3. Monitor intake and
output
4. Maintain bed rest
schedule activities to
provide undisturbed rest
period.
Dependent:
1.Adminester
progesterone 200 mg/caps
ule BID, Dexamethasone 6
mg IM q12 x 4 doses ref.
every day, Isoxsuprine
D5W 500 cc + 5 ampules
of Isoxsuprin e @ 6
ugtts/min., Magnesium
sulfate as doctors order
Reminder: Please provide references for your scientific basis discussion and for every rationale. Follow APA 6th ed. Guidelines to in-text citations and writing preferences
Name:
Clinical Instructor:
RATIONALE
Room :
EVALUATION
After 16 hours of nursing
1. Changes in vital
intervention, the patient
signs may be used for was able o:
rough estimate of
blood loose
> Demonstrate improve
2.Symptomatology
fluid balance as
may be useless in
evidenced by stable vital
gauging severity or
signs and good skin
length of bleeding
turgor.
episode
3.Provide guidelines
>Goal partially meet
for fluid replacement
4. Activity increase
intrabdominal
pressure and can
predispose to further
bleeding
Dependent:
1.To manage and
prevent excessive
vaginal bleeding
2.Aids in establishing
blood needs and