Nursing Diagnosis : Risk for Hypovolemic Shock related to continuous bleeding.
Goal :
- Shock does not occur during the treatment period.
- 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.
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.