Ric James R.

Mortel BSN 4E
ICU BOLOMSH exposure June 29, 2010
Baseline Data:
Name of the Pt.: FRB Chief complaint: abdominal pain, fever
Age: 84 y.o. Admitting diagnosis: T/c Acute Pyelonephritis can’t R/O Acute Abdomen DMII, HCVP
Gender: Female
Nursing Care Plan (Risk)

Assessment data Nursing Rationale Desired Nursing interventions Justification Evaluation

diagnosis outcome

Actual/abnormal Risk for Excessive intake After 3days of

cues: impaired skin of fluids nursing Independent:
integrity intervention, the
 Presence of related to fluid patient will be  Closely asses skin for any  To monitor any
edema in both retention and Excessive able to: alterations abnormalities for
lower and upper edema hypotonic or
 Provide adequate early treatment.
extremities isotonic IV fluids
Definition:  Maintain clothing/covers; protect
 Intake exceeds  To prevent
output Altered intact skin from drafts. Limit/avoid use
epidermis or Interstitial to and of plastic materials (e.g., vasoconstriction.
 Changes in
electrolytes dermis plasma fluid shift mucous Moisture
rubber sheet, plastic backed
membranes
Reference: linen savers). Remove potentiates skin
Risk factors:
Nurse’s Pocket Excess water will  Maintain wet, wrinkled linens
• Age (84y/o) breakdown.
Guide (11th Ed.) retain in ECF proper promptly.
• Environment Marilynn E. positioning
al factors Doenges, Mary every 3
Frances  Develop repositioning  To enhance
hours.
• Lifestyle Moorhouse, Edematous on schedule for client, understanding
Alice C. Murr both upper and involving client in reasons
lower extremities and cooperation.
• +Diabetes for and decisions about
Mellitus,
times and positions in
 To reduce
• +Hypertensi Risk for impaired conjunction with other
skin integrity pressure
on activities.
on/enhance
circulation to
Strengths:  Use appropriate padding
compromise
devices when indicated
tissues.
 Good family (e.g., pillows)
Support
 Faith in God  To reduce
pressure