Assessment Subj. (none) Obj. Change in mental state: -Restlessness -Anxious VS: -BP- 90/50 -T- 35.

4 -PR- 130 -RR- 27 -Urine Output: 25 ml/hr -Cool clammy skin -Capillary refill <2 sec. -HCT- 57% (increased) -Platelet 28,000 -Hgb- 7mg/dl

Diagnosis P: Deficient Fluid Volume related to E: Active volume loss as evidenced by S: hemorrhage/ trauma.

Planning Short Term: After 4 hours of nursing interventions, the patient will report understanding of causative factors for fluid volume deficit.

Intervention Independent: Establish rapport Monitor and record VS Assess patients condition

Rationale To gain patients trust To obtain baseline data To be aware of the patients condition and feeling

Evaluation Short term: After 4 hours of nursing interventions, the patient report understanding of causative factors for fluid volume deficit.

Monitor Input& Output balance To ensure accurate picture of fluid status Maintain Adequate hydration, increase fluid intake To prevent dehydration &maintain hydration status. To prevent from dryness Very young and extremely elderly individuals are quickly affected by fluid volume deficit. To deliver fluids accurately and at desired rates. Long Term: After 3 days of Nursing Interventions, the patient maintained fluid volume at functional level AEB well hydrated, intake is equal as output, and normal skin turgor.

Long Term: After 3 days of Nursing Interventions, the patient will maintain fluid volume at functional level AEB well hydrated, intake is equal as output, and normal skin turgor.

Provide frequent oral care

Determine effects of age.

Collaborative: Administer Intravenous fluids as prescribed

Restrict solid food intake, as indicated

To allow for bowel rest and to reduce intestinal workload. To prevent or limit occurrence of fluid deficit.

Discuss individual risk factors/ potential problems and specific interventions

Assessment Subj. The patient states Aray ang sakit

Diagnosis P: Acute Pain related to E: movement of bone fragments as evidenced by S: patient complaint of pain.

Planning Short Term: After 15-30 mins. of nursing intervention the patient will verbalize relief of pain. Long Goal: - After 1 hour of rendering care and interventions, the patient will be able to have an improved feeling of control and comfort.

Nursing Intervention Independent: Assess pain characteristics

Rationale

Evaluation Short Term:

Obj. VS: Change in mental state: -Restlessness -Anxious VS: -BP- 90/50 -T- 35.4 -PR- 130 -RR- 27

Quality, Severity, Location, Onset, Duration, Precipitating or relieving factors Some people deny the experience of pain when present. Attention to associated signs may help the nurse in evaluating pain. In the midst of painful experiences patient's perception of time may become distorted. Prompt responses to complaints may result in

After 15-30 mins. of nursing intervention the patient verbalized relief of pain. Long Goal: After 1 hour of rendering care and interventions, the patient is able to improved feeling of control and comfort.

Observe or monitor signs and symptoms associated with pain, such as BP, heart rate, temperature, color and moisture of skin, restlessness, and ability to focus.

Respond immediately to complaint of pain.

decreased anxiety in patient. Provide rest periods to facilitate comfort, sleep, and relaxation. A quiet environment, a darkened room, and a silent phone are all measures geared toward facilitating rest.

Collaborative: Administer medication as prescribed.

Assessment Subj. The patient states I feel like Im going to die

Diagnosis P: Anxiety related to E: stress as evidenced by S: restlessness.

Planning Short Term: - After 8 hrs shift of duty of rendering care and interventions, the patient will be able to understand the complications about his condition and able to control his anxiety. through proper Long Term: - After 3-5 days of rendering care and interventions, the patient will be able to accept the reality about his condition and readily participates in activities.

Nursing Intervention Independent: Establish rapport

Rationale

Evaluation Short Term: - After 8 hrs shift of duty of rendering care and interventions, the patient is able to understand the complications about his condition and able to control his anxiety. through proper Long Term: - After 3-5 days of rendering care and interventions, the patient is able to accept the reality about his condition and readily participates in activities.

Obj. VS: Change in mental state: -Restlessness -Anxious VS: -BP- 90/50 -T- 35.4 -PR- 130 -RR- 27

To have a trusted nurse to patient relationship and to have a therapeutic communication. Continuity of care promotes security and development of rapport. Accurate information about his condition reduces fear, strengthens the nurse-patient relationship and assist the patient and family to face the situation realistically. To reassure the patient that frequent monitoring may prevent him to develop of more serious complications.

Provide continuity of care

Encourage patient and S.O to verbalize concerns and fears.

Inform them that frequent assessment are routinely done to monitor her condition and dont necessarily imply a deteriorating condition.

Repeat the information Anxiety decreases as necessary because learning and patient and family may attention. reduce their attention span. Provide a comfortable And quiet environment. A comfortable environment enhances coping mechanisms and reduces myocardial workload and oxygen consumption.

Collaborative: Encourage the patient and family to ask questions and bring up common concerns. Sharing information elicits support and comfort and can relieve tension and unexpressed worries.

HYPOVOLEMIC SHOCK
A 38 year old traffic officer was admitted in the Emergency room after being hit by a bus in front of a mall. He was brought in stretcher with a broken right leg; squirting bright red blood. Upon assessment his initial vital signs are as follows: O2 sat 86%, blood pressure 90/50, respiratory rate of 27, and pulse rate of 130 beats per minute and a temperature of 35.4 Co. The patient weight is 70kg and height of 58. His skin was cold and clammy and the capillary refill was less than 2 sec. the estimated blood loss was around 1000 ml. He was immediately hooked to O2 inhalation at 10 liters per minute and EKG reading showed his arterial blood gas reading pH=7.20, HCO3=17, CO2=36. CBC= Hct= 57% Hgb=7 mg/dl WBC= Na+= K+= < 3.5 mEq/1 (4.7-6.1 /L = RBC) (0.42-0.52 g/L) (140-180 g/L) (5-10 x /L) (135 - 145 mEq/L) (3.5 - 5.0 mEq/L)

His urine output from foley catheter an hour is 25ml. He was given an IV line of D5LR 1 liter X 40 gtts/min. another line of PLR 1 liter fast drip 200 ml remaining to run for 8hrs. X-ray shows complete fracture of the right tibia.