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
clients 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