CLIENT INITIALS: D.

Jose NURSING CARE PLAN HUMAN PATTERN:

DATE: 9/16/2020 PRIORITY CONCEPT:
NURSING DIAGNOSIS: Deficient Fluid Volume Q Qty Reg Exchanging Valuing Perceiving
RT: Hypovolemia
AEB: Dehydration Cell in Seg Mob Communicating Choosing Knowing

. S/P/C Relating Moving Feeling

Planning Goal
Assessment Diagnosis Desired Outcome Implementation Rationale Evaluation Goal Met?
(Specific/Measurable) Nursing Interventions
Pertinent Data: Patient Will: Nurse Will: Why: What Happened: Yes No
Subjective:
(What did client Deficient SHORT TERM  Assess skin  The patient After 4 hour of *
say – use direct Fluid Volume GOAL: turgor and will have dry Nursing
quotations) r/t After 4 hours, mucous skin and Intervention the
Hypovolemia, The patient will membranes for mucous patient has regain
as evidence regain normal fluid signs of membranes. normal fluid
“I feel weak and by balance. dehydration. Tenting of the balance.
dizzy” as skin will
Dehydration
verbalized by the occur. The
patient tongue may
have
longitudinal
furrows.

 Assess vital  A BP drop of *

Objective: signs, especially more than 15
(What did you noting BP and mm Hg when
see/hear/smell/feel HR for orthostatic changing
– list findings) changes. from supine
to sitting
- Dehydrated position, with
- Dry oral a concurrent
 mucous elevation of
membrane 15 beats per
s and min in HR,
tongue indicates
- Poor skin reduced
turgor circulating
- Sunken fluids.
eyeball
- BP 94/40  Assess color,  Urine volume
*
- HR 110 concentration, will decrease,
- EKG and amount of urine specific
widening urine. gravity will
QRS increase, and
complex color will be
and darker.
increase  Assess trends in  Rapid weight
PR interval weight. loss will occur *
- Cortisol with fluid
2mg/dL volume
deficit.
 Assess for  These are *
fatigue, sensory signs of
deficits, or hyperkalemia.
muscle Aldosterone
weakness, which deficiency
may progress to leads to
paralysis. potassium
retention by
the kidneys.
 Signs of
*
 Assess hyperkalemia
electrocardiogra are sharp
m rhythm, as peaked T
available, for wave and
signs of widened
hyperkalemia. QRS
 complex.

 Abnormal
laboratory *
 Assess additional findings
indicated include
laboratory tests. hyperkalemia
(related to
aldosterone
deficiency
and
decreased
renal
perfusion),
hyponatremia
(related to
decreased
aldosterone
and impaired
free water
clearance),
and increase
in blood urea
nitrogen
(related to
decreased
glomerular
filtration from
hypotension).

 Patient
bruises
 Observe for easily. *
petechiae.  As sodium
 Encourage oral loss *
fluids as the increases,
 patient tolerates. extracellular
fluid volume
decreases.
These
interventions
are
necessary to
prevent fluid
volume deficit
because the
kidneys are
unable to
conserve
sodium.

 Sweating
increases *
 Instruct the sodium loss.
patient to ingest
salt additives in
conditions of
excess heat or
humidity.
 Increase in
LONG TERM GOAL: knowledge
After 2 days *
 Provide verbal can manage
The patient will and written the disease
experience fluid instructions and properly and
volume and verbal feedback minimize the
electrolyte balance as about the causes problem.
evidence by normal and effects of not
BP, Heart Rate and taking long-term
normal skin turgor. cortisone drugs.  This is
 important *
 Continuous component of
Monitoring the patient care,
Vital sign BP, to determine
Heart rate and feedback on
skin turgor the treatment.

*If the client goal was/was not met briefly describe why and what steps would be taken next