Nursing Diagnosis In Nursing

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6.0 NURSING CARE PLAN Nursing diagnosis Outcome Nursing intervention Evaluation Electrolyte Imbalanced related to excessive fluid loss as evidenced by BUSE result showed low Sodium 102 (Normal 135-145mmo/L) and patient vomiting 2 times in ETD. Patient will maintain electrolyte levels within normal limits or showed improvement in Sodium result during hospitalisation. 1. Assess patient for any physical signs of electrolyte imbalance such as cardiac, neurologic, and musculoskeletal symptoms so that early nursing intervention can be done to patient 2. Obtain the BUSE sample and evaluate the results to allow for prompt diagnosis and treatment of any abnormalities. 3. Administer intravenous fluids as ordered to promote the correction of low sodium…show more content…
Patient will improve his oral intake to normal amount during hospitalization. 1. Monitor oral intake and output to rule out any imbalance nutrition. 2. Provide a diet prescribed for patient’s specific condition such as soft diet to provide patient’s needed nutrition. 3. Allow and involve family member in care of the patient’s, such as give porridge frequently in small amount to provide needed nutrition to patient. 4. Monitor blood glucose levels (HPC) to identify hyperglycaemia or hypoglycaemia. 5. Record amount, color, and consistency of patient’s vomitus and stools as vomitus and stool characteristics indicate status of nutrient absorption. 6. Provide or assist with oral hygiene to help keep patient comfortable. 19/12/2014 @ 1.30 pm. Patient’s oral intake is improved as evidenced by patient able to eat 1 bowl of porridge during meal…show more content…
Assess the skin all over the body especially at the bony prominence area as baseline data. 2. Monitor skin condition at least once a day for any signs and symptoms of skin breakdown such as redness of skin for early detection of skin problem and early actions can be taken. 3. Reposition the patient 2 hourly to reduce pressure on bony prominence areas. 4. Change all the wet or dirty linen immediately to prevent softening of skin and cause skin breakdown. 5. Keep the bed linen wrinkled-free and free from particles to prevent skin irritation and eventually skin breakdown. 6. Keep the head of bed at not more than 30 degree as tolerated by patient to prevent sliding down of patient in which can cause pressure over the buttock area, causing skin breakdown. (Ralph & Taylor, 2014 ) 19/12/2014 @ 1.30 pm. Patient’s skin maintains intact with no signs of skin breakdown. 7.0 HEALTH EDUCATION • Encourage patient to increase the intake of oral sodium chloride in meal to improve the serum sodium

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