SUBJECTIVE DATA: NURSING DIAGNOSIS: INTERVENTIONS:

I have a lot of blood loss when I was Ineffective breathing pattern Administer supplemental 02 2-
operated because of my ectopic related to oxygen deficiency. 3L/min via nasal cannula 1
pregnancy as verbalized by patient. Administer and monitor blood
EXPECTED OUTCOME: transfusion 2
I am having a hard time breathing
After 2 hours of nursing intervention,the Monitor Vital Signs 1,2,3,4
as verbalized by patient. patient will establish a normal, Administer IV fluids (PNSS), and
effective respiratory pattern as
My wound in the abdomen hurts ensure correct IV regulation ,2
evidenced by:
until now as verbalized by the RR: 20 cpm Promote complete bed rest
patient. Absence of nasal flaring without BRP, 1,2,3
Calm and non-labored Encourage deep breathing
I had my operation just last night as breathing exercise, 1,3
verbalized by the patient. SpO2 of 98%-99%
Monitor pulse oximetry 1
Encourage adequate rest
OBJECTIVE DATA: periods between activities, 1,2,3
Nasal Flaring NURSING DIAGNOSIS: Administer Ketorolac 30 mg TIV
Pallor Fluid volume deficit related to
q6h. 3
Capillary refill of 5 seconds hemorrhagic loss Administer Tramadol 50 mg TIV
Poor skin turgor q6h. 3
SPO2= 92% EXPECTED OUTCOME: Monitor I&0 2
Pursed lip breathing After 8 hours of nursing intervention,
Promote proper hand hygiene
2000cc hemoperitonium the patient will maintain fluid volume by all caregivers and visitors. 4
Dry and pale mucus at a functional level,as evidenced by; Provide wound care to the
membrane abdomen.4
Bp of 90-120/60-80 mmHg and
Vital Signs: Maintain aseptic technique in
HR of 60-100
BP: 80/50mmHg Urine output of 30-60cc per providing wound care 4
HR: 117 bpm hour Monitor rate and depth of
Temp: 37.1 C Good skin turgor
respirations1
RR: 26 cpm Capillary refill of 2-3 sec.
Promote safe and calm
With O2 via nasal cannula at environment.1,3
2-3 Lpm
NURSING DIAGNOSIS: Observe for further blood loss 2
Dyspnea
Monitor patients visitors and
Fatigue Acute pain related to surgical limit visiting hours 4
Urine output of 30 cc/hr. incision
Pain Scale 7/10
Facial grimace EXPECTED OUTCOME:
Guarding behavior, hands on After 30 minutes of nursing
her abdomen intervention, the patient will be able
to:
Rate pain as 4-5/10
Absence of facial grimace
Absence of guarding behavior

DIAGNOSTICS:

Hemoglobin: 10.7 ( ) NURSING DIAGNOSIS:

Hematocrit: 0.32 ( )
RBC count: 3.66 ( )
WBC count: 22.6( )
Segmenters: 87% ( )
Lymphocytes: 11% ( )
Monocyte:2%( )
Risk for infection related to
presence of post- surgical incision
EXPECTED OUTCOME:
After 3 days of nursing intervention,
the patient will remain free of infection
as evidenced by:
Absence of fever