NURSING CARE PLAN

ASSESSMENT NURSING PLANNING INTERVENTIONS RATIONALE EVALUATION

DIAGNOSIS

Subjective Cue: Fluid volume Within 24 Independent: After 24 hours

deficit related to hours of 1. Monitor vital signs  To assess the of effective
active loss as effective baseline date nursing
Objective Cues: manifested by: nursing interventions
 Restlessness interventions 2. Monitor intake and  To monitor signs the patient
 Weakness  Restlessness such as output of dehydration fluid volume
 Dry lips  Weakness monitoring was remain
 Pale  Dry lips Intake and 3. Assess for skin  To monitor signs adequate as
conjunctiva  Pale output, turgor and oral of dehydration evidenced by:
conjunctiva providing oral mucous membranes  Decrease
fluids restlessness
Initial Vital replacement 4. Cover patient lightly,  To prevent  No
Signs: and avoid overheating. vasodilation, weakness
administering blood pooling in  No dry lips
T- º C prescribed extremities and  Red
P- bpm IVF and reduce conjunctiva
R- cpm medication circulating blood
BP- mmHg the patient volume. Latest
fluid volume Vital Signs
Intake= 2550 will remain 5. Encourage the  To replace the
Output= 1980 adequate. patient to drink oral loss fluids.
fluid Intake= 3850
Output= 2600
6. Provide oral hygiene  To promote
patients interest
in drinking.
7. Keep oral fluids at
bedside within  To give patient
patient’s reach some control
over fluid intake
8. Provide complete
bed rest  To promote
relaxation
9. Teach causes of
fluid losses  To give info.
which is the key
in managing
problem
10. Explain, give
information or  For the
 NURSING CARE PLAN

ASSESSMENT NURSING PLANNINIG INTERVENTIONS RATIONALE EVALUATION

DIAGNOSIS
Subjective Cue: Hyperthermia Within 6 hours Independent:
related to of effective 1. Monitor vital signs  To assess the After 6 hours
Objective Cues: dehydration as nursing baseline data of effective
 High body manifested by: interventions 2. Remove excess nursing
such as such clothing and covers  To decreases
temperature interventions
as tepid warmth and
 Restlessness  High body the patient’s
sponge bath, increases
 Teary eye temperature
removing evaporative temperature
 Warm skin  Restlessness
excess cooling was able to
 Chills  Teary eye
 Warm skin clothing and 3. Provide Tepid decrease from
Sponge Bath  To reduce high
Initial Vital administering evidenced by:
body
Signs: antipyretics
4. Control temperature
the patient’s  Decrea
temperature environmental se
temperature  To promote
will be cooling process restlessness
decrease from and reduce core  (-)
temperature warm skin
5. Provide drop light  (-) chills
 To decrease
patients Latest
6. Explain the temperature Vital Signs
temperature  To have active
measurement and cooperation
treatments to the
parent of the client

7. Give information  To have

regarding normal knowledge and
temperature and participation in
control their child
 condition

Dependent:

 IV therapy as  To promote
ordered hydration

 Paracetamol as  To decrease the

prescribed temperature
when there’s
fever