1. Assessment Overview
Key areas to assess on admission:
- Vital signs and hemodynamic stability (temperature, heart rate, blood pressure, respiratory rate, SpO).
- Level of consciousness and neurological status.
- Fluid balance: intake, output, signs of dehydration or hemorrhage.
- Skin integrity presence of rash, petechiae, ecchymoses, or pressure ulcers.
- Respiratory function cough, dyspnea, need for supplemental oxygen or ventilation.
- Renal function urine output, creatinine, electrolytes.
- Laboratory values: CBC, coagulation profile, liver enzymes, viral load.
- Psychosocial status anxiety, fear, family support, cultural considerations.
- Infectioncontrol compliance (PPE use, hand hygiene).
2. Nursing Diagnoses
| Nursing Diagnosis | Related Factors | Defining Characteristics |
|---|---|---|
| Risk for Fluid Volume Deficit | Persistent vomiting, diarrhea, fever, capillary leak | Decreased urine output, dry mucous membranes, tachycardia |
| Impaired Skin Integrity | Severe rash, pressure from immobilization, invasive lines | Redness, blistering, ulceration |
| Acute Pain | Myalgia, abdominal cramps, headache | Verbal reports of pain, facial grimacing, increased BP |
| Risk for Infection Transmission | Highviralload bodily fluids, breach of PPE | Potential exposure of staff or other patients |
| Anxiety | Fear of death, isolation, unfamiliar environment | Restlessness, rapid speech, inability to concentrate |
3. Goals and Expected Outcomes
- Patient will maintain adequate fluid balance as evidenced by urine output 0.5mL/kg/hr and stable vital signs within 48hours.
- Skin will remain intact or show improvement of any existing lesions within 72hours.
- Pain will be reduced to a selfreported level of 3/10 within 1hour of intervention.
- No secondary transmission events will occur during the patients ICU stay.
- Patient will verbalize reduced anxiety and demonstrate coping strategies by day 3.
4. Nursing Interventions
| Diagnosis | Intervention | Rationale |
|---|---|---|
| Risk for Fluid Volume Deficit |
| Maintains intravascular volume, prevents shock and organ hypoperfusion. |
| Impaired Skin Integrity |
| Prevents pressure injuries and secondary infection from viral lesions. |
| Acute Pain |
| Effective pain control improves respiratory effort, hydration, and overall comfort. |
| Risk for Infection Transmission |
| Reduces exposure of staff and other patients to Ebola virus. |
| Anxiety |
| Alleviates emotional distress, which can otherwise exacerbate physiological instability. |
5. Evaluation
Evaluation should be performed at the end of each shift and documented in the patients record. Compare actual outcomes with the expected goals:
- Fluid status review I&O, weight, labs.
- Skin note any new breakdown or healing progress.
- Pain reassess pain scale after each intervention.
- Infection control audit PPE compliance and any breach reports.
- Psychological ask the patient to describe feelings of fear or calmness.
If goals are not met, modify the plan: adjust fluid rates, change analgesic regimen, request woundcare specialist, or increase frequency of psychosocial support.
All interventions must be carried out in accordance with local, national, and World Health Organization (WHO) Ebola treatment guidelines.
