Student: Mya Bentley

Date: 5/8/14 PTs Initials:LD Llll D

Data Clustering
(Subjective and
Objective)

72YOF
A&O x 4
Dx with Colitis
CC: BRBPR
&N/V/D x 2 days,
Admitted 5/5/14
NPO IVF NS
100ml/hr
Cipro
400mg/200ml
IVPB Q 12 hrs
Flagyl
500mg/100ml
IVPB Q 6 hrs
Admission wt
77.27kg,5/6/14
77.5 kg
Skin non tenting
Ouput: 5/6/14
900ml dark
yellow clear
urine(day shift)
Intake 800ml via
IV
VSS Q 4 hrs 96.669-18-124/6299%3LNC
VSS 97.6-85-20147/72100%3LNC
Labs 5/5/14:
WBC 16.0,Hgb
12.9,Hct 38.1,K+
4.5,BUN 27
Labs 5/6/14:
WBC
12.5,Hgb11.1,
Hct 32.8,
K+3.7,BUN 15
Nursing Diagnosis

Outcomes
(Must be specific
Measurable, realistic,
have a time frame.)
Outcome 1

Prioritized Nursing Diagnosis Care Plan

Nursing Actions
Assessment /Monitor

Pts VS will trend toward

baseline of 96.6-85+18124/62-99% 3LNC

Monitor VS Q 4 hrs

Outcome 2

Assessment/Monitor

Pt will remain A&O x4 q

4 hrs

Monitor level of
consciousness q 4 hrs

Outcome 3

Assessment/Monitor

Pts I/O will be within +/200ml q shift

Outcome 4

Monitor I and O q shift

Intervention
(Independent)

Scientific Rationale
(Reason your nursing actions will prevent, solve or lessen the
stated nsg dx problem) *DO NOT FORGET REF. Pg #*
In mild to moderate fluid volume deficit,compensatory
mechanisms include SNS stimulation of the heart rate and,
combined with vasoconstriction, maintains the blood
pressure within normal limits. A change in position from lying
to standing may elicit further increase in HR or a decrease in
BP (orthostatic hypotention). If vasoconstriction and
tachycardia provide inadequate compensation, hypotension
occurs when the pt is recumbent. Severe FVD can cause
weak and thready pulse, severe FVD can result in
hypovolemic shock.
Ref: Lewis pg 310
Changes in neurologic function may occur with FVD or FVE.
ECF excess may result in cerebral edema as a result of
increased hydrostatic pressure in cerebral vessels.
Alternatively, profound volume depletion may cause an
alteration in sensorium secondary to reduced cerebral tissue
perfusion. Assessment of neurologic status includes : LOC,
pupil size and response, and voluntary movement of
extremities.
Ref: Lewis pg 310

The use of 24 hour intake and output records gives valuable

information regarding fluid and electrolyte problems. Sources
of excessive intake or fluid losses can be identified on an
accurately recorded intake and output flow sheet. Intake
should include oral,IV, and tube feedings and retained
irrigants. Output includes urine,excessive perspiration, wound
or tube drainage, vomitus , and diarrhea. Measure urine S.G.
Readings of greater than 1.025 indicate concentrated urine,
where as those of less than 1.010 indicate dilute urine.
Ref: Lewis 310

Clues to ECF volume deficit and excess can be detected by

inspection of the skin. Examine the skin for turgor and

Risk for FVD r/t bloody,

diarrhea stools and NPO
status

Goal Statement

Pt will maintain fluid

volume balance

Pt skin will be non

tenting q 4 hrs

Assess skin turgor q 4

hrs

Outcome 5

Intervention
(Independent)

Pts weight will be +/- 4.4

kg of admission weight
of 77.27kg

Monitor weight daily.

Outcomes
(Must be specific Measurable,
realistic, have a time frame.)

Nursing Actions

Outcome 6

Intervention (Independent)

Pts Hct levels will be 3747% and Hgb levels will be

12-16g/100ml every 6
hours

Monitor hemoglobin and Hct

levels q 6 hour for 24 hours

Outcome 7

Intervention (Independent)

Pts BUN will be between 721mg/dl daily.

Monitor BUN levels daily

Outcome 8

Intervention (Independent)

mobility. Normally a fold of skin, when pinched, will readily

move and, on release, will rapidly return to its former
position. Skin areas over the sternum, abdomen, and anterior
forearm are the usual sites for evaluation of tissue turgor.
Decreased skin turgor is less predictive of FVD in older
persons d/t loss of skin elasticity. In ECF volume deficit, skin
turgor is diminished; there is a lag in the pinched skinfold's
return to its original state (referred to as tenting). The skin
may be cool and moist if there is vasoconstriction to
compensate for the decreased fluid volume.
Ref: Lewis pg 310

Monitor pts weight daily. Accurate daily weights provide the

easiest measurement of volume status. A decrease in weight
could be sign of fluid volume loss. A decrease of 1 kg is equal
to 1000mL of fluid lost. Weight changes must be obtained
under standardized conditions. An accurate weight requires
that the pt be weighed at the same time of day, with the
same amount of clothing, and on the same calibrated scale.
Ref: Lewis pg 310

Scientific Rationale
(Reason your nursing actions will prevent, solve or lessen the stated nsg dx
problem)
*DO NOT FORGET REF. Pg #*

Monitor Hgb and Hct every 6 hours as ordered. When there is an

excess loss of RBD and when there is an excess of IV fluids which can
cause a dilution effect values are decreased. In bleeding or
hemorrhage, the Hct drops several hours after the bleeding episode.
The severity of the drop in value correlates directly with the amount
of blood loss.
Ref: In class handout
Blood Urea Nitrogen is the end product of protein breakdown.
Produced in the liver and excreted via the kidneys. Normal levels are
between 7-21mg/dl in adults. BUN assist to evaluate hydration status
and renal function along with Cr levels. The amount of urea excreted
is dependent upon the state of hydration and renal perfusion. If pt is
dehydrated tubular flow will be low increasing the absorption of urea
thus increasing BUN.
Ref: In class handout
Potassium is the most abundant intracellular electrolyte in the body's cells.

Pts Potassium levels will

remain between 3.55mEq/L daily

Monitor potassium levels

daily

Outcome 9

Dependent actions (MD

order)

Pt WBC count will trend

toward normal (5,00010,000/mm3) daily

Administer Metronidazole
500mg/100ml IVP Q 6 hr per
MD order

Outcome 10

Dependent actions (MD

order)

Normal values range from 3.5-5mEq/L in adults. Potassium assists in normal

function of neuromuscular tissue, including relaxation of the heart muscle &
contraction of the skeletal muscles. Hypokalemia can result from fluid losses
from gastrointestinal tract, skin, kidneys, as well as from decreased po
intake or alkalosis.
Ref: In class handout

Administer Metronidazole 500mg/100ml IVP Q 6 hr per MD order.

Metronidazole is used to treat intestinal infections like colitis and
diarrhea (which can lead to FVD). Metronidazole is a direct-acting
trichomonacide and amedicide that works inside and outside the
intestines. It's thought to enter the cells of microorganisms that
contain nitroreductase, forming unstable compounds that bind to
DNA and inhibit synthesis, causing cell death.
Ref: Lippincott Williams & Wilkins pg 62

Pt WBC count will trend

toward normal (5,00010,000/mm3) daily

Administer Ciprofloxacin
400mg/200ml in D5W q 12
hours per MD order

Outcomes
(Must be specific Measurable,
realistic, have a time frame.)

Nursing Actions

Outcome 11
Pt will receive 800ml of NS
via IV q shift.

Dependent actions (MD

order)
Administer 0.9% Sodium
Chloride via IV @ 100ml/hr
per MD order

Administer Ciprofloxacin 400 mg/ 200ml in D5W q 12 hours as

ordered. Ciprofloxacin is used to treat a variety of infections;
ordered for my patient to treat colitis. Ciprofloxacin works primarily
by inhibiting bacterial DNA synthesis, mainly by blocking DNA
gyrase; bactericidal.
Ref: Lippincott Williams & Wilkins pg 212

Scientific Rationale
(Reason your nursing actions will prevent, solve or lessen the stated nsg dx
problem) *DO NOT FORGET REF. Pg #*

FVD can occur with abnormal loss of body fluids

(diarrhea,hemorrhage,drainage, and polyuria), inadequate intake, or
a shift of fluid from plasma into interstitial fluid. The goal of FVD is to
correct the underlying cause and to replace both water and
electrolytes. Parenteral fluid replacement is indicated to prevent or
treat hypovolemic complications. Balanced IV solutions like lactated
Ringer's solution, are usually given. Isotonic (0.9%) sodium chloride
is used when rapid volume replacement is indicated. Blood is
administered when volume loss is d/t blood loss.

Ref: Lewis pg 309 & NCP pg 78

Outcome 12
Pt WBC count will decrease
daily reach levels between
5000-10000/mm3 with
antibiotic therapy

Dependent actions (MD

order)
Obtain WBC as ordered q 1-3
days

Outcome 13

Dependent actions (MD

order)

Pt will remain NPO q shift

until orders changed

Initiate NPO status per MD

order

Referral

No Out Come
For this Nursing
Action

Refer to gastroenterology

Outcome 14

Patient Teaching

Pt will recite s/s of FVD

daily

Teach pt s/s of decreased

fluid volume daily

Outcome 15
Pt will recite interventions
to implement when there
is FVD daily

Patient Teaching
Teach interventions to
prevent future episodes of
FVD daily

Obtain WBC count as ordered. An increasing WBC count indicates

body's effort to combat pathogens. Normal WBS levels are 500010000/mm3. Very low WBC count can indicate severe risk for
infection because pt does not have sufficient WBC to fight infection.
Ref: NCP pg 107
Initiate NPO status in pt for treatment of colitis. One of the initial
goals of treatment for pts with colitis is to rest the bowel. Colitis
usually starts in rectum and moves in a continual fashion toward the
cecum. Placing pt on NPO status allows the bowel to rest and
inflammation to subside and facilitate a faster recovery. Intestinal
areas effected by colitis are inflamed and can become further
irritated with the passage of fecal matter delaying healing and
recovery.
Ref: Lewis pg 1023

Pt will be referred to gastroenterology for treatment of colitis.

Gastroenterologist is a physician that specializes in issues of the GIT.
A gastroenterologist would have a better understanding of diseases
of the intestinal system and how best to treat them. Referring
patient to gastroenterology can aid in curing colitis through surgical
measures.
www.nlm.nih.gov
Teach pt signs and symptoms of FVD. Some signs of FVD are
hypotension, tachycardia, increase in temperature, weak and
thready pulse, and change in mental status. Increasing the patient's
knowledge level will assist in preventing and managing the problem.
Ref: NCP pg 78 & Lewis pg 310
Teach pt some interventions to implement when there is a potential
for FVD. Patients need to understand the importance of drinking
extra fluid during bouts of diarrhea, fever, and other conditions
causing fluid deficits. Other interventions could be to take antidiarrheal or anti-emetic medications to prevent excess vomiting or
diarrhea.
Ref:NCP pg 78