NURSING CARE PLAN

Dulay, David Audrey H.

Saint Louis University

Be OB Ward Duty

Prof. Diadem Depayso

 NURSING DIAGNOSIS
 Vomited up to 10 times in 24
hrs. and has not managed to
tolerate any food in 3 days
 Can only drink a few amounts of
water
 Feels very weak and produces
small dark urine outputs.
 Dry mucus membranes
 Vital signs of:
Temperature- 37°C
BP- 115/68 mmHg
HR- 96/min
 Urinalysis reveals:
Decreased Potassium= 3.0
mmol/L from the normal of 3.3-
4.1 mmol/L
Concentrated Urea= 8.2 mmol/L
from the normal of 2.4-4.3
mmol/L
Nsg. Dx:
Deficient fluid volume related to
active fluid loss secondary to pregnancy
as manifested by vomiting 10 times in
24 hrs.
EXPLANATION OF THE
PROBLEM
Deficient Fluid Volume is defined
as decreased intravascular,
interstitial and/or intracellular
fluid. This refers to dehydration,
water loss alone without change
in sodium. Deficient fluid volume
is a state or condition where the
fluid output exceeds the fluid
intake. It happens when water
and electrolytes are lost as they
exist in normal body fluids. Since
the patient is at her first
trimester, it is just normal for her
to experience hyperemesis
gravidarum wherein she suffers
from extreme vomiting as a
result of increase in HCG
hormone in the blood. Having
hyperemesis gravidarum forces
her to vomit and excrete a lot of
fluid from her body, hence the
nursing diagnosis.
References:
Wayne G., (2019, March 20).
Deficient Fluid Volume.
Nurseslabs. Retrieved
from:
https://nurseslabs.com/
deficient-fluid-volume/
Hyperemesis gravidarum:
MedlinePlus Medical
Encyclopedia. (n.d.). STO:
Retrieved May 15, 2020, After 8 hours of nursing
GOALS AND INTERVENTION RATIONALE EVALUATION
OBJECTIVES
GOAL: Monitor vital signs Dehydration alters body’s FULLY MET if able to maintain
The patient will be able especially blood vital signs. For the blood normal fluid volume all
to achieve adequate pressure, pulse rate and pressure, first, when the throughout until discharge
fluid volume temperature body's cells lack water, the
brain sends a signal to the PARTIALLY MET if temporarily
pituitary gland to secrete achieved, but then, becomes
vasopressin, a chemical that deficient again
causes constriction of the
blood vessels to save fluids. NOT MET if patient never
On the other hand, achieved adequate fluid
dehydration also causes volume
higher viscosity of the
blood, thus the increase in
LTO: blood pressure. When these
After 3 days of nursing happen, the heart will then FULLY MET if lab results show
intervention, the compensate by contracting normal potassium and urea
patient’s urinalysis will faster, the reason for levels after 3 days
reveal a normal increased pulse rate. Lastly,
potassium value to fluids regulate body PARTIALLY MET if lab results
within 3.3-4.1 mmol/L temperature, so, the lack of show an increase in
and urea level to within it results to inability to potassium level and a
2.4-4.3 mmol/L from 3.0 regulate homeostasis decrease in urea level,
mmol/L and 8.2 mmol/L, resulting to fever. If the however, are still not within
respectively patient’s vital signs increase, normal ranges or a normal
then, immediate level of just one
rehydration will be
necessary. (Vascular NOT MET if lab results show
Institute. (2019, October 1). similar results or worse
The Importance of (lower potassium level and
Hydration for Your Heart. higher urea concentration)
Retrieved May 15, 2020,
from
https://share.upmc.com/20
14/09/importance-
from intervention, the patient hydration-heart/)
https://medlineplus.gov/ will be able to: Assess skin turgor, oral
ency/article/001499.htm mucosa and eyes Lack of fluid in the body will
1. Increase her result to drying of epithelial FULLY MET if fluid intake is
fluid intake to membrane like the mucous increased to as least 1.5L
1.5-2L from only and cutaneous membranes.
‘few amounts’ Skin turgor of >2 sec. PARTIALLY MET if fluid intake
suggests dryness of the skin, is more then ‘few amounts’
thus dehydration. Same but is still under 1.5L
goes with dry mucous
membranes. If the patient NOT MET if fluid intake is still
displays these signs, then, ‘few amounts’
she must be dehydrated,
therefore, the need to
2. Excrete provide appropriate nursing FULLY MET if urine is colored
yellowish-amber interventions like yellowish to amber
colored urine rehydration and regulation
from being dark- of I.V. fluids. (Rice PARTIALLY MET if urine is
colored University. (2013, March 6). colored orange
Types of Tissues. Retrieved
May 15, 2020, from NOT MET if urine is still dark
http://pressbooks- in color
dev.oer.hawaii.edu/anatom
yandphysiology/chapter/typ
3. Expel a total es-of-tissues/) FULLY MET if urine output is
amount of at Note color and amount at least 240Ml
least 240 ml of of urine, as well as Change of urine color to a
urine from urinalysis results darker one and urine output PARTIALLY MET if urine
‘small amounts’ of less than 30ml/hour output is greater than ‘small
denote possible amount’ but does not reach
dehydration. Lack of fluid 240 mL
results to a more
concentrated urochrome in NOT MET if urine output is
the urine, thus the change still ‘small amount’
in color. Also, if there is
deficient fluid in the body, it
will also result to decrease
in urine output. If the
4. Display moist patient’s urine continues to FULLY MET if mucous
mucus be darker and lesser than membranes appear moist
membrane from usual, and her lab results
being dry show abnormalities in PARTIALLY MET if mucous
normal value like the excess membranes appear slightly
of urea, it may suggest that dry
she is still dehydrated,
hence the need for NOT MET if mucous
Ensure accurate intake rehydration. membranes still appear dry
and output recording
Intake and output records
show the amount of fluids
the patient takes in and out.
If the patient’s I&O record
shows that she is still
expelling more fluid than
what she takes, she may still
experience dehydration,
thus, the need to increase
Offer at least 1.5-2L of her fluid intake.
water
Offering water to the
patient and urging her to
consume it will replace the
fluids lost, hence
rehydrating her.
Rehydration will then help
in treating the patient and
return her normal body
functioning. Since the
patient has been vomiting a
lot, rehydrating it with at
least 1.5L of water will
Regulate I.V. fluid replace the lost fluids from
vomiting

I.V. fluids help in hydration.

Regulating the appropriate
amount of I.V. fluid entering
the body will help in
rehydrating the cells.
Ensuring the proper I.V.
 fluids will result to her
rehydration
Enumerate other
sources of fluids like
fruits and healthy Giving the mother other
beverages options may help her in
taking more fluids. She can
choose foods or beverages
that she prefers which will
aid in rehydration. This will
make rehydrating more
enjoyable for her
Emphasize the
importance of
increasing the fluid Emphasizing makes the
intake mother more
knowledgeable about why
fluid intake is important,
thus, increasing
participation

REFERENCES: Wayne, G., Wayne, G., & Wayne. (2019, March 20). Deficient Fluid Volume – Nursing Diagnosis & Care Plan. Retrieved from https://nurseslabs.com/deficient-fluid-volume/