CNA253 AT3: Nursing Diagnosis and Interventions for Ms. L

CNA253 AT3 1
CNA253 AT3
By Student’s Name
Course + Code
Class
Institution
Date

CNA253 AT3 2
CNA253 AT3
Scenario
Ms. L, a 39 years old lady.
Two Priority Nursing Diagnosis
1. Deficient fluid volume related to vomiting and increase in hematocrit as evidenced by
patient passing regular small bouts of vomiting and feeling nausea with a hematocrit
of 50%
2. Acute pain related to vomiting and bowel distention as evidenced by patient waving
on the upper abdomen when asked about pain and failing to void.
Reason for the prioritization
1. Deficient fluid volume is a priority diagnosis due to the fact that the patient exhibited
hydration characteristics such as weak pulse, reduced skin turgor, capillary refill
greater than three seconds, dry mucous membrane, pale and cool to touch and
increase in urine concertation. Other than that, the patient has been having small bouts
of vomiting with little oral intake
2. Acute pain is a priority as it put the patient in distress. Ms. L when asked about, she
just pointed at her upper abdomen without speaking meaning she is in deep pain. S
Goals, Actions, and Evaluation
Diagnosi
s 1
Goal Related Actions Rationale Evaluate
outcomes
Deficient
fluid
volume
To maintain Ms.
L with adequate
body fluid
volumes by
maintaining the
1. Monitor Ms. L
vital signs and
record as
required
(Gulanick, and
1. Ms. L is in
distressed and has
difficulty in
breathing with a
capillary refill greater
1. The pulse rate
should increase
and become
stronger with a
capillary refill