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Name : Age: Civil Status:

Residence : No. of Admission in this Hospital:


Nationality : Gender: Date and Time of Admission:
Impression/Diagnosis : Occipital mass secondary to liver metastasis; Anemia secondary to occipital mass

Date Cues/Data Nursing Scientific Basis Goal of Nursing Rationale Evaluation


Diagnosis Care Intervention
August Subjective: Deficient Definition: After 45 After 45
19, -prior to fluid Decreased minutes of minutes of
2010 admission, he volume intravascular, nurse- nurse-client
experienced related to interstitial, client interaction,
bleeding hemorrhag and/or interaction the client
-2nd operation e intracellular fluid. , the client was able to:
was stopped due This refers to will be able
to hemorrhage dehydration, to: -assess vital -to obtain a.Elicit signs
-abrupt change water loss alone signs baseline of
of position without change a.Elicit -weigh the data developmen
triggers bleeding in sodium. signs of client -to know the t
developme extent of -bleeding
Objective: Relationship of nt -stop blood fluid loss has stopped
-consumed 3 L Problem to loss -to avoid -patient is
PNSS Etiology: -administer severe fluid comfortable
-consumed 2 Hemorrhage is fluids as volume
bags of PRBC an active fluid b.Start indicated. deficit b.Start fluid
and still need to volume loss that fluid Replace -to volume
secure another was not properly volume blood effectively replacement
-took 7 seconds replaced. Excess replaceme products as and quickly therapy as
for his toenail to in blood loss nt therapy ordered replace fluid evidenced
refill does not only -control by:
-fingernails and contain the RBC humidity -to prevent -increase of
toenails were but also the -position excess oral fluid
pale other client sweat intake
-bp: 100/50 compartments of comfortably adding to -
mmHg the blood. -note insensible attachments
-palpebral and client’s water loss of IV fluid
bulbar Own Analysis: preference -to minimize -started
conjunctiva were If too much blood of food high pressure on blood
pale is lost, the body in fluid the wound transfusion
tries to -keep fluid -to aid in
-decreased Hgb compensate but within reach fluid
6.0 because this loss and replacement
-decreased Hct is in extent and encourage -to avoid
0.18 was not properly intake client from
replaced the doing
Repeat blood body can no unnecessary
test longer things
-decreased RBC compensate thus
3.26 M/UL resulting to
-decreased Hgb deficit in fluid
8-6 L g/dl volume. Pale skin
-decreased Hct and delayed refill
26% are some of the
-decreased MCH manifestations;
25 Pg this is due to
decrease supply
of blood. Blood is
also helpful in
fighting off
foreign materials
that is present in
the impaired skin
integrity
resulting to
increased
workload or
function of the
blood.

Source:
Marilynn E.
Doenges et. Al,
Nurse’s Pocket
Guide Diagnoses,
Prioritized
Interventions and
Rationales
edition II, page
published by FA
Davis Company

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