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    Patient Care Record - Nursing Care Plan: University of Santo Tomas College of Nursing Espa

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    cleahis cruz
    The nursing care plan document summarizes care provided to a patient in labor. It notes that the patient is receiving IV fluids for a risk of fluid volume deficit from lack of oral intake and diaphoresis. The nursing diagnosis is risk for fluid volume deficit. Objectives are to maintain adequate fluid volume and electrolyte balance based on vital signs, adequate urinary output, and understanding of withholding food and fluids during labor. Nursing interventions include assessing hydration status and vital signs, monitoring urinary output, providing oral and skin care, and administering IV fluids as ordered. The goal of maintaining normal vital signs and skin integrity was met.

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    Patient Care Record - Nursing Care Plan: University of Santo Tomas College of Nursing Espa

    Uploaded by

    cleahis cruz
    27 views2 pages
    The nursing care plan document summarizes care provided to a patient in labor. It notes that the patient is receiving IV fluids for a risk of fluid volume deficit from lack of oral intake and diaphoresis. The nursing diagnosis is risk for fluid volume deficit. Objectives are to maintain adequate fluid volume and electrolyte balance based on vital signs, adequate urinary output, and understanding of withholding food and fluids during labor. Nursing interventions include assessing hydration status and vital signs, monitoring urinary output, providing oral and skin care, and administering IV fluids as ordered. The goal of maintaining normal vital signs and skin integrity was met.

    Original Description:

    NCP for Acute labor pain

    Original Title

    NCP-RLE-VER-2.0

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    The nursing care plan document summarizes care provided to a patient in labor. It notes that the patient is receiving IV fluids for a risk of fluid volume deficit from lack of oral intake and diaphoresis. The nursing diagnosis is risk for fluid volume deficit. Objectives are to maintain adequate fluid volume and electrolyte balance based on vital signs, adequate urinary output, and understanding of withholding food and fluids during labor. Nursing interventions include assessing hydration status and vital signs, monitoring urinary output, providing oral and skin care, and administering IV fluids as ordered. The goal of maintaining normal vital signs and skin integrity was met.

    Copyright:

    © All Rights Reserved
    Download as DOC, PDF, TXT or read online from Scribd
    Download as doc, pdf, or txt
    27 views2 pages

    Patient Care Record - Nursing Care Plan: University of Santo Tomas College of Nursing Espa

    Uploaded by

    cleahis cruz
    The nursing care plan document summarizes care provided to a patient in labor. It notes that the patient is receiving IV fluids for a risk of fluid volume deficit from lack of oral intake and diaphoresis. The nursing diagnosis is risk for fluid volume deficit. Objectives are to maintain adequate fluid volume and electrolyte balance based on vital signs, adequate urinary output, and understanding of withholding food and fluids during labor. Nursing interventions include assessing hydration status and vital signs, monitoring urinary output, providing oral and skin care, and administering IV fluids as ordered. The goal of maintaining normal vital signs and skin integrity was met.

    Copyright:

    © All Rights Reserved
    Download as DOC, PDF, TXT or read online from Scribd
    Download as doc, pdf, or txt
    of 2

    UNIVERSITY OF SANTO TOMAS COLLEGE OF NURSING

    Espaa Blvd., Manila, Philippines 1015


    PATIENT CARE RECORD - NURSING CARE PLAN

    DATE

    CUES/CLUES

    NURSING
    DIAGNOSIS

    RATIONALE

    OBJECTIVE

    NURSING
    INTERVENTION

    ANALYSIS

    EVALUATION

    OBJECTIVE DATA:

    11/12/2016

    The patient was


    receiving IV Fluid
    (NSS) with
    Oxtocyin as side line
    flowing at 20
    gtts/min
    Vital Signs:
    BP = 130/90
    RR= 20
    PR= 85
    Temperature = 36.8
    C

    SUBJECTIVE DATA:
    The client verbalized
    Nauuhaw po ako. Pahingi
    po ako ng tubig.

    PROBLEM
    ETIOLOGY:
    Risk for fluid
    volume deficit
    related to
    prolonged lack of
    oral intake and
    diaphoresis

    Labor pain often results


    from the degree of
    dilation of your cervix,
    from the position or
    descent of the baby and
    from the strength of your
    contractions.

    SHORT TERM:
    After the shift,
    the client will
    maintain
    adequate fluid
    volume and
    electrolyte
    balance based
    on the Normal
    VS.
    Adequate
    urinary output.
    Verbalize
    understanding
    of withholding
    food and fluids
    during labor
    Demonstrate
    behaviors to
    monitor and
    prevent
    dehydration as
    indicated.

    INDEPENDENT:
    1. Assess
    patients
    hydration
    status and
    monitor vital
    signs.
    2. Observe
    urinary output,
    color, measure,
    and amount.
    3. . Provide
    frequent oral
    and skin care.
    4. Discuss
    importance of
    withholding
    food and water
    during the
    entire labor
    course.
    DEPENDENT:
    1. Administer IV
    fluids as
    ordered to
    maintain fluid
    balance.

    To obtain
    baseline data and
    to determine
    alterations in
    fluid volume and
    electrolyte
    imbalance
    To maintain skin
    integrity, prevent
    dehydration and
    preserve kidney
    function.
    To prevent
    aspiration which
    can lead to
    respiratory
    distress.

    GOAL IS MET; Maintained v/s within


    normal range and
    exhibited moist
    mucous membrane;
    has good skin turgor,
    and prompt capillary
    refill.

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