Nursing Informatics

Activity IV
Submitted by:

Florie Mae Morandarte

C O M P L E X I T Y

WISDOM

KNOWLEDGE

INFORMATION

DATA

HUMAN INTELLECT

 Vital Signs:

Hydatidiform Mole

Temperature36.4C Pulse Rate68 bpm Respiratory Rate18 cpm Blood Pressure90/60 mmHg

Chief complaint:
Vaginal bleeding that varies from dark brown spotting for 1 day duration. 3 days PTA, Mrs. Smith experienced excessive vomiting that occurs in the morning. O> Urinalysis test for hCG revealed positive, UTZ revealed multiple small cystic structures, negative for fetal parts and fetal heart beat.

 Fluid volume deficit r/t elevated levels of human Chorionic Gonadotropin (hCG) from the proliferating trophoblasts. Gestational trophoblastic disease encompasses several disease processes that originate in the placenta. These include complete and partial moles, placental site trophoblastic tumors, choriocarcinomas, and invasive moles.

 Assess skin turgor and moisture of mucous membranes Indicators of hydration status/ degree of deficit
- Monitor Vital signs. Evaluate peripheral pulses, capillary refill to have a baseline data, reflects adequacy of circulating volume - Monitor I&O; include all output sources (e.g., emesis, diarrhea Decreasing renal output and concentration of urine suggest developing dehydration and need for fluid replacement. - Weigh daily Sensitive measurement of fluctuations in fluid balance - Observe for bleeding tendencies; Note the amount, lochia/color of the vaginal discharge Early identification of problems (which may occur as a result of cancer), allows for prompt intervention.

 Encourage increase fluid intake as tolerated To compensate with the fluid volume deficit problem
Encourage ice chips on mouth For the vomiting episodes Encourage rest Prevent unnecessary energy expenditure related to vomiting (as may trigger) and bleeding (loss of blood/RBC)

The patients hospital records should be kept confedential and private. Keep the patient safe at all times.