NURSING INTERVENTION

Risk for Fluid Volume Deficit   

• Monitor body weight
• Monitor fluid intake and output
• Monitor BP and heart frequency
• Evaluation of skin turgor, capillary refill and mucous membrane conditions
• Give fluid intake 3-4 L / day
• Inspection of skin / mucous membranes for petechiae, ecchymoses area; noticed bleeding gums, blood color of rust or vague in feces and urine, bleeding from the puncture further invasive.
• Implement measures to prevent tissue injury / bleeding
• Limit oral care to wash mouth when indicated
• Give diet a smooth
• Collaboration:
  • Give IV fluids as indicated
  • Supervise laboratory tests: platelet count, Hb / Ht, freezing
  • Provide HR, platelets, clotting factors
  • Maintain a central vascular access device external (sub-clavicle artery catheter, tunneld, implantable ports)
   

 Acute Pain

• Assess complaints of pain, notice changes in the degree of pain (using a scale of 0-10)
• Monitor vital signs, note the non-verbal clues such as muscle tension, anxiety
• Provide quiet environment and reduce stressful stimuli.
• Place the client in a comfortable position and prop joints, extremities with pillows.
• Change the position of periodic and soft assistive range of motion exercises.
• Provide comfort measures (massage, cold compresses and psychological support)
• The review / enhance client comfort interventions
• Evaluate and support the client's coping mechanisms
• Encourage the use of pain management techniques. Example: relaxation exercises / breathing in, touch.
• Auxiliary therapeutic activity, relaxation techniques.
• Collaboration: Monitor levels of uric acid, give the medication as indicated.