Nursing Actual NCP PDF

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Summary

Download Nursing Actual NCP PDF

Description

Bondoc, Jan Dale

BSN 2B group A

ACTUAL NCP Assessment

Explanation of the problem

Objective

Intervention

S> - Patient reported that she experienced light spotting over the past two day

Insufficient or excessive hormone levels generally result in spontaneous miscarriage. Infectious, immunologic, and environmental factors come to play on firsttrimester pregnancy lost. Incomplete abortion usually is indicated by vaginal bleeding, accompanied by abdominal pain. The cervical os may be open with products of conception being passed.

Short term after 2 hours of effective nursing intervention: - Excessive bleeding will be stopped - Patient blood volume will be restored - Patient’s blood pressure will be maintained above100/60 - Patient’s pulse rate will be maintained below 100 bpm

Dx  Monitored vital signs

O> - Moderate active bleeding noted in the vaginal vault with the cervical os open - Blood clots or tissue on the peripad noted Initial Vital signs - BP-124/84 - HR-83bpm - RR-18bpm - SpO2-100% - Temp-98.3F Diagnosis> Fluid volume deficit related to blood loss secondary to incomplete abortion

Source: https://emedicine.medscap e.com/article/795085overview#a5

Long term after 8 hours of effective nursing intervention: - Patient blood volume will be maintained - Patient blood volume will be restored - Patient’s blood pressure will be maintained above100/60 - Patient’s pulse rate

 Changed peri pad

 Positioned patient flat in bed on her side  Monitored blood loss by weighing used pads

Tx  Administered 1 liter of normal saline via IV  Administered Methergine as ordered

Rationale

 A change in vital signs may indicate complications  A prolonged pad in the perineal area may lead to infection  Promotes comfort

 Weighing the pads is used to estimate the blood loss of the patient

 To retore the fluid volume loss  Used to control excessive bleeding

Evaluation

Goals met  Excessive bleeding stopped  Patient’s blood volume restored and maintained  Patient’s blood pressure maintained above100/60  Patient’s pulse rate maintained below 100 bpm

will be maintained below 100 bpm

 Assisted patient in ambulation

Edx  Encouraged patient to drink fluids as tolerated  Educated the patient to clean the perineal area from front to back  Educate patient about medications being administered

Perineal tissue damage resulting to Impaired urinary elimination Edema

 Ability to ambulate independently is needed prior to discharge  To restore the fluid volume loss

 Front to back motion will prevent infection  Helps relieve anxiety and promotes compliance...