FABRO

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FABRO, Prinzes Dyoana M.

October 3, 2023
UB SON BSNII / NBD2 NCLMCA1: OB-GYNE WARD, BONTOC GENERAL HOSPITAL

Patient: A. M. B.
Chief Complaint: Acute pain on the IV site
Nursing Diagnosis: Acute pain related to IV Infiltration as evidenced by Edematous Intravenous Site

ASSESSMENT NURSING DIAGNOSIS PLANNING IMPLEMENTATION RATIONALE EVALUATION


Subjective Data: Infiltration happens when the STO: Dx: Dx: STE:
“Nasakit diyay ayan iti IV catheter is not correctly After 2 hours of nursing 1. Assessed intravenous 1. Confirms patency After 2 hours of nursing
dextrose ko” as verbalized by positioned within the vein or interventions, the client must site during IV therapy interventions, the goals were
the patient. due to patient’s excessive be able to demonstrate proper and throughout the met, the patient was able to
movement making the IV and suitable sleeping course of treatment. demonstrate proper and
Objective Data: catheter to be dislodged and positions and report that pain 2. Assessed present suitable sleeping positions
Pain Scale: 7/10 instead enters the surrounding is manageable with a pain health status by 2. Presents the baseline and reported pain scale of
BP: 120/80 tissue. This misplacement scale of 4/10. monitoring vital signs data for any changes 2/10.
PR: 107 allows fluids being or fluctuations in pain
RR: 24 administered through the IV LTO: and discomfort.
SPO2: 96 to leak into the adjacent After 8 hours of nursing 3. Assessed and LTE:
tissue, causing edema. interventions, the edematous evaluated the skin’s 3. Early diagnosis and After 8 hours of nursing
- Visible bulging of IV Resulting to: Acute pain intravenous site of the patient overall condition, categorization of interventions, the edematous
catheter site related to IV infiltrations as will completely subside, with including its color, edema could lead to intravenous site of the patient
- Grimaces when evidenced by edematous a display of improved vein texture and severity best prognosis and completely subsided, with a
moving arm intravenous site. integrity and will be able to of edema. avoid complications. display of improved vein
- -Slowed limited report good skin integrity integrity and was able to
movement with a pain scale of 1/10 to 4. Discontinue IVF of 4. Stop the regulation of report good skin integrity.
less pain. D5LRS 1L and D5W. IVF’s to avoid
increasing the size of
bulging and prevent
the patient to feel any
further pain and
5. IV catheter removed discomfort.
and reinserted to right
arm using gauge 18 5. Continue IVF therapy
IV catheter using without
aseptic technique. compromising the
previous IV insertion
site.
6. Above IVF
consumed and
replaced to same IVF 6. Helps in relaxing the
of D5LRS 1L x 24° smooth muscles of
and side drip of D5W the uterus, promote
500mL + 4 amps of vasodilation, and
isoxsuprine, prevents contractions.
regulated to
10gtts/min.

Tx:
7. Assisted in a Tx:
comfortable position. 7. Contributes to a more
positive patient
8. Provided therapeutic recovery experience
measures such as arm and can improve the
repositioning. physical and mental
quality of life.
9. Kept the edematous
skin clean
8. Avoid IV flow
10. Seen at times. interruption and IV
site infiltration.

9. Avoid further
infection and another
possibility of edema.

10. Help in mitigating


risks and ensure that
the patient receives
the best possible care
Edx: Edx:
11. Encouraged hot 11. Applying heat to the
compress on previous inflamed area will
IV site. dilate the blood
vessels, promote
12. Encouraged the blood flow, and help
patient to avoid sore and tightened
touching the IV site muscles relax.
and putting too much
pressure on it. 12. To avoid movements
or actions that might
make the IV catheter
to dislodge.

13. Helps in decreasing


13. Reiterated complete stress, reducing
bed rest with assisted pressure on the cervix
bathroom privileges and abdomen, and
helps in reducing
blood pressure.

14. Determine the


14. Advised to report any efficacy of
signs of pain and interventions and
discomfort. treatment progress.

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