Nurse Care Plan
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NURSING DIAGNOSIS
EXPECTED OUTCOMES NURSING INTERVENTIONS
RATIONAL OF INTERVENTIONS-EBN
EVALUATION
P: Ineffective Protection
Patient has reduced risk of bleeding aeb platelets within acceptable limits, and absence of overt bleeding
Avoid nonessential invasive procedures, punctures, and injections
Reduce risk of bleeding
Goal met, no invasive procedures today
Maintain fall precautions, side rails up, bed alarm on
Reduce risk of trauma
Goal met, no falls or trauma
Monitor and report any sign of infection (fever, chills, flushed skin, drainage, edema, abnormal lab values and pain and promptly notify physician if occurs
Patient assessed at beginning of shift and every 2 hours with vital signs
Goal met
Plan and promote rest periods, cluster nursing interventions to promote rest
Rest lowers the body’s Goal met, patient oxygen requirements and remained in bed decreases pulmonary strain throughout the shift
E: R/T abnormal renal function S: aeb: lab values (BUN 43), electrolyte imbalance NA+ 151, CL 109, RBC 3.1, HGB 9.7, Platelets 1.5
EXPECTED OUTCOMES NURSING INTERVENTIONS
RATIONAL OF INTERVENTIONS-EBN
EVALUATION
P: Ineffective Protection
Patient has reduced risk of bleeding aeb platelets within acceptable limits, and absence of overt bleeding
Avoid nonessential invasive procedures, punctures, and injections
Reduce risk of bleeding
Goal met, no invasive procedures today
Maintain fall precautions, side rails up, bed alarm on
Reduce risk of trauma
Goal met, no falls or trauma
Monitor and report any sign of infection (fever, chills, flushed skin, drainage, edema, abnormal lab values and pain and promptly notify physician if occurs
Patient assessed at beginning of shift and every 2 hours with vital signs
Goal met
Plan and promote rest periods, cluster nursing interventions to promote rest
Rest lowers the body’s Goal met, patient oxygen requirements and remained in bed decreases pulmonary strain throughout the shift
E: R/T abnormal renal function S: aeb: lab values (BUN 43), electrolyte imbalance NA+ 151, CL 109, RBC 3.1, HGB 9.7, Platelets 1.5
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