CASE SCENARIO/SITUATION:
Elaine, a 32 year old patient arrived in the emergency room with severe vaginal bleeding. Upon entering the ER patient is still conscious and coherent.
Subjective: I feel dizzy and weak. I feel like I am about to faint
15 minutes later patient became unconscious
Vital Signs:
BP: 90/60
PR: 105 BPM
RR: 17 RPM
Temp: 36.2
O2 saturation: 90
GROUP #3
BEANCA NUñEZ,
CHARLENE JOY MOISES
DONNA LALOGO
JASMINE JAYME
JULIA ALEXANDRA GUIBO
JULIE ANNE CATAMBAY
KATHLENE MAE MEJICA
MARIA ALYSSA JIMENEZ
MICHAEL GABRIEL JIMENEZ
MIKAELA ANGELA GONZALES
RENZE IVANNE MORALES
ROSHIENA KAE OTADOY
ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION
SUBJECTIVE: Ineffective tissue Short Term: Independent: Independent: Short Term:
“I feel dizzy and weak. I perfusion related to After 1 hour of nursing >Evaluable reports of >To help isolate and After 1 hour of nursing
feel like I’m about to hypovolemia as interventions, the extremity pain promptly, differentiate problems interventions, the
faint.” as verbalized by evidenced by patient will be able to: nothing associated patient was able to:
the patient. hypotension, symptoms >To incorporate disease
tachycardia, decreased > Demonstrate management into > Demonstrate
OBJECTIVE: oxygen saturation increased perfusion as >Identify necessary activities of daily living. increased perfusion as
>15 minutes later individually appropriate changes in lifestyle and Promotes individually appropriate
patient became (e.g., skin warm and assist client independence, (e.g., skin warm and
unconscious dry, peripheral pulses enhances self-concept dry, peripheral pulses
present and strong, >Monitor patient’s vital regarding ability to deal present and strong,
>Severe vaginal absence of edema, free signs, especially Blood with change and absence of edema, free
bleeding of pain or discomfort) pressure, Pulse rate manage own needs. of pain or discomfort)
and Oxygen Saturation.
VITAL SIGNS: >Verbalize Look for signs of >Hypotension and >Verbalize
BP: 90/60 understanding of risk orthostatic hypotension. tachycardia are initial understanding of risk
PR: 105 bpm factors or conditions, compensatory factors or conditions,
RR: 17 bpm therapy regimen, side > Check for optimal fluid mechanisms usually therapy regimen, side
Temp: 02 sat: 90% effects of medications, balance. noted with bleeding. effects of medications,
and when to contact Orthostasis (a drip of 20 and when to contact
healthcare providers. mm Hg in systolic BP or healthcare providers.
10 mm Hg in diastolic
Long Term: BP when changing from Long Term:
After 2 days of nursing supine to sitting After 2 days of nursing
interventions, the position) indicates interventions, the
patient will be able to: reduced circulating patient was able to:
fluids. Monitoring these
>Demonstrate vital signs can help to >Demonstrate
behaviors and lifestyle prevent different worse behaviors and lifestyle
changes to improve case scenarios. changes to improve
circulation (e.g., engage circulation (e.g., engage
in regular exercise, in regular exercise,
cessation of smoking, > Sufficient fluid intake cessation of smoking,
weight reduction, maintains adequate weight reduction,
disease management) disease management)
filling pressures and
optimizes cardiac output
needed for tissue
perfusion.
ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION
Dependent: Dependent:
>Administer
medications such as >These reduce blood
antiplatelet agents,
viscosity and
thrombolytics,
antibiotics coagulation. To break
up or dissolve blood
>Administer fluids, clots.
electrocytes, nutrients,
and oxygen as >To promote optimal
indicated. flow, organ perfusion,
and function.
>Administer IV fluids
and blood products as
ordered by the >To maintain circulating
physician. volume and tissue
perfusion.
Collaborative:
> Consult with a
Collaborative:
neurologist to have a
neuro check on the
patient. >To monitor if there’s a
decreased oxygenation
>Consult an OB GYNE in the organs especially
to determine the in the brain.
patient’s cause of
vaginal bleeding
>To have a further
examination, to identify
the cause of vaginal
bleeding, and to know
the possible
medications needed.
