IV.

NURSING CARE PLAN

DATA
NURSING DX
Subjective:
Sagunson
iyahang sukaha
ug kalabad sa
iyang ulo maong
gipa admit
dayun amu sya.
As verbalized by
the patients
father

Risk for Fluid

volume deficit
related to
vomiting

OBJECTIVES
Short term:
At the end 4
hours of giving
patients
intervention the
patient will
maintain the
balance of fluid
volume.

NURSING
INTERVENTIONS
Monitor vital signs

To obtain an
accurate record

Increase Fluid Intake

As her nausea
decreases encourage
her oral intake of
fluids as tolerated,
again to replace lost
volume

On assessment:

Lethargi
c
Skin
Pallor
Vital signs:
BP: 90/60
Temp: 37.0
RR: 25
PR: 84

To establish proper
baseline data

Monitor intake and

output

Objective:
Long term:
At the end 3 days
of giving patients
intervention the
patient will not
experience
vomiting and can
maintain balance
fluid volume.

RATIONALE

EVALUATION
At the end of 8
hours of giving
patients
intervention the
goal was partially
met as evidenced
by maintain of
fluid balance.

DATA
Subjective:

Diagnosis

Objectives

Nursing Intervention

Rationale

Evaluation