Risk for Hypovolemic Shock, Risk for Metabolic Acidosis and Self-care Deficit


Nursing Diagnosis : Risk for Hypovolemic Shock related to continuous bleeding.

Goal :
  • Shock does not occur during the treatment period.
Expected Outcomes:
  • Not decreased consciousness.
  • Vital signs within normal limits.
  • Good skin turgor.
  • Good peripheral perfusion (acral warm, dry and red).
  • Fluid balance in the body.

Nursing Interventions :
1. Encourage the patient to drink more.
R /: Increased fluid intake, may increase intravascular volume, which can increase tissue perfusion.

2. Observation of vital signs every 4 hours.
R /: Changes in vital signs can be an early indicator of dehydration.

3. Observation of the signs of dehydration.
R /: Dehydration is the beginning of the syock if dehydration is not in good hands.

4. Observation of fluid intake and output.
R /: adequate fluid intake can compensate for excessive discharge.

5. Collaboration in:
  • Intravenous fluids or transfusion.
  • Giving coagulant and uterotonic.
  • CVP custom installation.
  • Examination of the plasma density.

Nursing Diagnosis : Risk for Metabolic Acidosis related to a decrease in the amount of blood in the capillaries.

Goal :
Metabolic acidosis did not occur during the treatment period,

Expected Outcomes:
  • The results of blood gas analysis within normal limits.
  • Vital signs within normal limits.
Nursing Interventions :
1. Observation vital signs within normal limits.
R /: Changes in vital signs is an early sign of detection of acidosis.

2. Encourage and motivate patients to drink sweet.
R /: Reducing protein breakdown and excessive fat to meet metabolic needs.

3. Collaboration in:
  • BGA inspection.
  • Intravenous fluids.

Nursing Diagnosis : Self-care Deficit related to physical weakness

Goal :
During the treatment period of daily activity needs are met.

Nursing Interventions :
1. Explain to the patient about the importance of maintaining personal hygiene.
R /: Adequate knowledge enables clients cooperatively towards the maintenance action performed.

2. Assist the client in meeting the nutritional needs (food and drink).
R /: Weakness of the body requires that the client needs with the help of others.

3. Assist the client in meeting the needs of personal hygiene.
R /: Weakness of the body that occur can lead to inability to meet the needs of personal hygiene.

4. Observation fulfillment daily activities.
R / Increased ability fulfillment of daily needs may reflect reduced body weakness.

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