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Prevents spread
3. Limit use of invasive of infection via
devices or procedure as airborne
possible droplets.
L
4. Inspect wounds or site of May provide
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Prevents
5. Maintain sterile technique introduction of
when changing dressings, bacteria,
suctioning or providing site reducing risk of
care. nosocomial
infection.
COLLABORATIVE:
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Objective: Deficient Short term goal IMPLEMENTATION RATIONALE Short term goal
Patient is Fluid volume After 8 hours of INDEPENDENT: Goal not met,
unconscious with nursing After 8 hours of
related to
GCS of 3/15 intervention 1. Monitor and Decrease in circulating nursing
(E1V1M1) subarachnoid Client will be able document vital signs blood volume can cause intervention
hemorrhage. to maintain fluid especially BP and HR. hypotension and Client wasn’t
Dry lips and volume at a tachycardia. Alteration able to maintain
mucus functional level as in ** is a compensatory fluid volume at a
membranes evidence by stable mechanism to maintain functional level as
vital signs, moist cardiac output. Usually, evidence by
Edema on both mucous the pulse is weak and unstable vital
arms membranes and may be irregular if signs, dry mucous
adequate urine electrolyte imbalance membranes and
Hypotension (BP output also occurs. Hypotension inadequate urine
of 60/30 mmHg) 2. Asses skin turgor and is evident in output.
Long term goal: oral mucus membranes hypovolemia.
Bradycardia (PR After 3-5 days of for signs of dehydration. Long term goal:
of 46 bpm) nursing Signs of dehydration are Goal not met,
intervention, the also detected through After 3-5 days of
Urine output of patient will be able 3. Assess color and skin. Longitudinal nursing
less than 20 cc/hr to: amount of urine output. bumps may be noted intervention, the
Be normovolemic Report urine output less along the tongue. patient was not
as evidenced by than 30 ml/hr. able to:
Creatinine level: systolic greater A normal urine output is Be
115.37 umol/L than or equal to 4. Administer parenteral considered normal not normovolemic
90 mmHg, fluids as prescribed. less 30 ml/hr. as evidenced by
absence of Consider the need for an Concentrated urine systolic greater
Chloride level: orthostasis, HR of IV fluid challenge with denotes fluid deficit. than or equal to
131.00 mmol/L 60-100 bpm, immediate infusion of 90 mmHg,
urine output of fluids. Fluids are necessary to absence of
Sodium level: 30ml/hr and maintain hydration status orthostasis, HR
163.00 mmol/L normal skin Determination of the of 60-100 bpm,
turgor 5. Provide comfortable type and amount of the urine output of
Demonstrate environment by fluid to be replace and 30ml/hr and
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lifestyle changes covering patient with infusion rate will vary normal skin
to avoid light sheets or light depending on clinical turgor
progression of clothing. status. Demonstrate
dehydration lifestyle changes
Drop situations where to avoid
patient can experience progression of
overheating to prevent dehydration
further fluid loss.
O
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Patient is Impaired Skin After 8 hours of 1. Determine age. Elderly patient’s skin is
unconscious with nursing normally less elastic and
Integrity has less moisture, making
GCS of 3/15 intervention, the
(E1V1M1)
related to patient will have for higher risk of skin
Neuromuscular her skin intact as impairment.
2. Evaluate patient’s
Patient is Function evidenced by consciousness of the Patient with diminished
attached to secondary to absence of sensation of pressure. sensation are unconscious
mechanical Immobility bedsores in any of unpleasant stimuli and
ventilator and ET part of the do not shift load. This
size 7.5, level 19 extremities. result in protracted
Fi02= 60% pressure on skin capillaries
tV= 360 3. Watch fluid intake and and in the end, skin
BUR= 16 hydration or skin and ischemia.
mucus membranes.
No response Monitor incidence of
dehydration or over
to any stimuli. 4. Boost tissue perfusion by hydration that affect
offering gentle massage circulation and tissue
around reddened or integrity at the cellular
blanched areas. level.
Moisture exacerbates
pruritus and augments risk
of skin breakdown.
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avoid unnecessary
pressure on skin or tissues.
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