UNIVERSITY OF SANTO TOMAS COLLEGE OF NURSING

Espaa Blvd., Manila, Philippines 1015

PATIENT CARE RECORD - NURSING CARE PLAN

DATE

CUES/CLUES

NURSING
DIAGNOSIS

RATIONALE

OBJECTIVE

NURSING
INTERVENTION

ANALYSIS

EVALUATION

OBJECTIVE DATA:

11/12/2016

The patient was

receiving IV Fluid
(NSS) with
Oxtocyin as side line
flowing at 20
gtts/min
Vital Signs:
BP = 130/90
RR= 20
PR= 85
Temperature = 36.8
C

SUBJECTIVE DATA:
The client verbalized
Nauuhaw po ako. Pahingi
po ako ng tubig.

PROBLEM
ETIOLOGY:
Risk for fluid
volume deficit
related to
prolonged lack of
oral intake and
diaphoresis

Labor pain often results

from the degree of
dilation of your cervix,
from the position or
descent of the baby and
from the strength of your
contractions.

SHORT TERM:
After the shift,
the client will
maintain
adequate fluid
volume and
electrolyte
balance based
on the Normal
VS.
Adequate
urinary output.
Verbalize
understanding
of withholding
food and fluids
during labor
Demonstrate
behaviors to
monitor and
prevent
dehydration as
indicated.

INDEPENDENT:
1. Assess
patients
hydration
status and
monitor vital
signs.
2. Observe
urinary output,
color, measure,
and amount.
3. . Provide
frequent oral
and skin care.
4. Discuss
importance of
withholding
food and water
during the
entire labor
course.
DEPENDENT:
1. Administer IV
fluids as
ordered to
maintain fluid
balance.

To obtain
baseline data and
to determine
alterations in
fluid volume and
electrolyte
imbalance
To maintain skin
integrity, prevent
dehydration and
preserve kidney
function.
To prevent
aspiration which
can lead to
respiratory
distress.

GOAL IS MET; Maintained v/s within

normal range and
exhibited moist
mucous membrane;
has good skin turgor,
and prompt capillary
refill.