FLUID VOLUME DEFICIT

A Nursing Care Plan presented to

The faculty of Nursing Department

In Partial Fulfillment of the

Requirements in NCM 209- RLE

PEDIATRIC ROTATION

Submitted to
Mrs. Ariane Mae Soriano, RN

Submitted by:
Khesler Bernie N. Bacalla
BSN-2E Group-3

April 20,2020
Name of Patient: R.M.P ____Attending Physician: Dr. Lim _____ Room No.: 304-3
Chief Complaint: Febrile for 3 days Diagnosis (if discharge): _____________________
Date Cues Need Nursing Patient Outcome Interventions Implementation Evaluation
& Diagnosis
Time
A Subjective: N Fluid volume Within 8 hours of 1. Monitor and 1 April 20, 2020 @
P “Way gana U deficit related nursing document vital 3:00 pm
R muinom ug T nausea, intervention, the signs especially “Goal was met”
I tubig akong R vomiting and patient will be BP and HR.
L anak, sige I bleeding as able to: R: Decrease in After 8 hours of
nalng syag T evidence by circulating blood nursing intervention,
2 suka ug gina I dry skin and a. Verbalized volume can patient was able to:
5, sunggo pud O poor skin awareness cause
sya” N turgor for hypotension a. Verbalized
2 / causative and awareness for
0 M Rationale: factors and tachycardia. causative
2 Objective: E Fluid behaviors Alteration in HR factors such
0 T imbalance essential is a as “ kabalo
-dry skin A can arise due to correct compensatory nako ngano
@ -dark yellow B to fluid deficit mechanism to ko nagniwang
urine O hypovolemia, b. Become maintain cardiac ug murag uga
7 -OFI of 30 cc L normovolemia normovol- output. kayo akong
A for 8 hours I with emic as 2. Assess skin 2 tutunlan”
M -restlessness C maldistributio evidence turgor and oral b. Become
-irritability n of fluid, and by systolic mucous normovolemic
-pale P hypervolemia. BP greater membranes for as evidence
conjunctiva A Trauma is than or signs of by BP of
-underweight T among the equal to 90 dehydration. 110/70
-poor skin T most frequent mm HG(or R: Signs of c. Increased oral
turgor E causes of patient’s dehydration are fluid intake as
R hypovolemia, baseline also detected evidence by
N with its often c. Increase through the skin consuming
profuse Oral Fluid
attendant intake form 3. Assess color 3 550cc of water
blood loss. 30cc/8H to and amount of in 8 hours
Another at least urine. Report
common 500cc/8 urine output
cause is hours less than 30
dehydration, ml/hr for 2 Khesler Bernie
which consecutive Bacalla St. N
primarily hours.
entails loss of R: A normal
plasma rather urine output is
than whole considered
blood. The normal not less
consequence than 30ml/hour.
s of Concentrated
hypovolemia urine denotes
include fluid deficit.
reduction in 4. Encourage 6
circulating increase fluid
blood volume, intake providing
lower venous appealing
return and, in liquids.
profound R: for hydration
cases, arterial
hypotension 5. Encourage to 7
avoid food that
Kreimeier, causes
U.(2000). dehydration
Critical Care. such as coffee
Retrieved and tea
April 20, 2020 R: to prevent
from further
https://www.n dehydration
cbi.nlm.nih.go
v/. 6. Ensure accurate 5
DOI: 10.1186 intake and
/cc968 output
monitoring
R: accurate
records are
critical in
assessing the
patient’s fluid
balance
7. Vitamins given 9
as ordered
R: to aid in the
general health
of the patient
8. Ensure proper 4
IVF
R: to ensure
there is
adequate
hydration
9. Antibiotics given 10
as ordered
R: to aid in
preventing
infection
10. Weight the 8
patient daily
R: changes in
weight can
provide
information in
fluid balance
 and the
adequacy of
fluid volume
replacement

References:
Herdman,T.H. & Kamitsuru (2018). NANDA International,Inc. Nursing Diagnoses Definitions and Classifications 11 th
edition.
Wayne, G. (2019). Fluid volume deficit. Retrieved April 20,2020 from https://nurseslabs.com/
Taghavi, S., Askari, R.,(2019). Hypovolemic shock. Retrieved April 20, 2020 form https://www.ncbi.nlm.nih.gov/
 RISK FOR BLEEDING

A Nursing Care Plan presented to

The faculty of Nursing Department

In Partial Fulfillment of the

Requirements in NCM 209- RLE

PEDIATRIC ROTATION

Submitted to
Mrs. Ariane Mae Soriano, RN

Submitted by:
Khesler Bernie N. Bacalla
BSN-2E Group-3

April 20,2020
Name of Patient: R.M.P ____Attending Physician: Dr. Lim _____ Room No.: 304-3
Chief Complaint: Febrile for 3 days Diagnosis (if discharge): _____________________
Date Cues Need Nursing Patient Outcome Interventions Implementation Evaluation
& Diagnosis
Time
A Subjective: S Risk for Within 8 hours of 1. Determine the 1 April 20, 2020 @
P “ gisungo A bleeding nursing intervention, patient’s health 3:00 pm
R akong anak, F related to the patient will be history for “Goal was partially
I 3 days E altered able to: signs that can met”
L straight na” T clotting factor be associated
Y a. Demonstrate with a risk for After 8 hours of
2 / behaviors bleeding such nursing
5, Objective: Rationale: that reduce as liver intervention,
P Hemostasis is the risk for disease, patient was able to
2 VS: R the process bleeding inflammatory
0 Temp: 39.0 O by which bowel disease,
2 BP:110/70 T bleeding is b. Stop himself or peptic a. perform
0 RR:26 E arrested after from bleeding ulcer disease behaviors
PR:92 C injury to blood by sitting R: Early that
@ T vessels. It is a down and identification of reduces risk
-restlessness I delicate firmly pinch possible risks for bleeding
7 -irritability O multiphase the soft part for bleeding such as:
A -bleeding N process that of the nose provides a using soft
M -abdominal involves foundation for bristled
pain interactions implementing toothbrush,
-petechae on between the c. Maintain vital appropriate limit
the upper blood signs within preventive straining
part of the vessels, normal range measures. bowel
back platelets and 2. Monitor 2 movements,
coagulation BP: 105/70- patient’s vital coughing
factors. A 115/80 signs, and blowing
-platelet defect in any Temp:36.6- especially BP
count of of these 37.2 C and HR. Look
25g/L phases of RR: 18-30 for signs of b. apply basic
-skin warm to coagulation PR:70-110 orthostatic hyp knowledge
touch can result in a d. otension. in stooping
-facial bleeding R: himself from
grimace problem Hypotension a bleeding by
which may be nd tachycardia pinching the
inherited or are initial soft part of
acquired. compensatory his nose
there is a mechanisms
delicate usually noted but
controlled with bleeding.
balance 3. Evaluate the 8 c. patient was
between patient’s use of not able to
formation and any maintain
dissolution of medications vital signs
a blood clot that can affect within
during the hemostasis normal
hemostatic R: Drugs that range
process. A interfere with
disruption of clotting BP: 110/70mmhg
this unique mechanisms Temp:38.7C
balance may or platelet RR:32cpm
cause activity PR:96bpm
bleeding or increased risk
thrombosis. for bleeding.
4. Use a soft- 3 Khesler Bernie N.
Bashawri, L., bristled Bacalla
Ahmed, M. toothbrush and
(2007). The nonabrasive
Approach to a toothpaste.
Patient With a Avoid the use
Bleeding of toothpicks
Disorder: for and dental
the Primary floss.
Care R: This
Physician. method
Journal of providing oral
Family and hygiene
community reduces
medicine. trauma to oral
Retrieved mucous
April 20, 2020 membranes
from and the risk for
www.ncbi.nlm bleeding from
.nih.gov. the gums.
PMCID: 5. Limit straining
PMC3410146 with bowel 4
movements,
forceful nose
blowing,
coughing, or
sneezing.
R: These
activities may
cause trauma
to the mucosal
linings in the
rectum, nasal
passages, or
upper airways.
6. Educate the
patient and 10
family
members
 about signs of
bleeding that
need to be
reported to a
health care
provider.
7. R: Early
evaluation and 10
treatment of
bleeding by a
health care
provider
reduce the risk
for
complications
from blood
loss.
8. advise
increased of 5
Oral Fluid
Intake
R: to prevent
dehydration
9. advise patient
to eat fruits 6
and
vegetables
that are high in
vitamin C
R: to boost up
immune
system
 10. advise patient
not to eat dark
colored foods. 7
R: as it may
alter the result
of the stool
exam in
determining if
there’s
presence of
blood/ if
there’s GI
bleeding

REFERENCES:
Herdman,T.H. & Kamitsuru (2018). NANDA International,Inc. Nursing Diagnoses Definitions and Classifications 11 th
edition.
Wayne, G.(2017). Risk for bleeding. Retrieved April 20,2020 from https://nurseslabs.com/
Novak, C.(2018). Pediatric vital signs reference chart. Retrieved April 20, 2020 from https://www.pedscases.com/