Kristopher Kirby 09/28/2020

Nursing Care Plan

SUBJECTIVE OBJECTIVE MODE:_Physiological__ NURSING

RATIONALES
DATA DATA NEED: Fluid & Electrolyte INTERVENTIONS
“I’m thirsty” 53 yo male admitted NURSING DIAGNOSIS 1. Administer Medications as ordered. 1. An understanding of
09/03/2020 for Risk for fluid volume deficient (D.M) pharmacology and practical
“This is the first dehydration, colitis, in r/t insufficient oral fluid knowledge about safe procedures
real food I’ve and hypmagnesemia intake and polyuria from DM A. Magnesium oxide 400mg po BID. will help ensure the safety and
eaten since I’ve and diuretics (D.R) health of the patient.(Teas p. 772)
been here” Hx of CHF, DM II,
CAD, HTN, MI, Priority B. Potassium Cloride 20MEQ po QD. A. Treatment/prevention of
“I was vomiting #__1_______________ (D.R) hypomagnesemia.
a lot when I first Labs (Davis p. 800)
got here but not 09/2 09/2 09/2 STG;_Pt. Will gain 12oz C. Ondansetron 4mg IVP Or po Q4H
so much now.” 5 6 7 without wet lung sounds by PRN for nausea/vomiting. (D.M) B. Treatment/prevention of
K+ 4.0 4.0 4.3
1430 on 09/28/2020 potassium depletion.
2. Monitor and document vital signs (Davis p. 1040)
Ma ? ? 1.7 EVALUATION especially BP and HR Q shift. (D.M)
Bun 42 42 33 Met__________________ C. Vomiting is a form of fluid
Partially Met* _________ 3. Assess skin turgor and mucouis loss. (Taber’s 23 p. 632)
Cre 2.15 1.92 1.58
Not Met*______________ membranes for signs of dehydration.
(D.M) 2. Weak rapid pulse and
IV 0.9% NS @ 100 Discharge Goal hypotension are signs of
ml/h continuously _Pt. Will be normovolemic by 4. Monitor Daily weights at the same dehydration. (Teas p. 1470)
discharge time every day. (D.M)
3+ Occult stool
samples on 09/27/2020 5. Monitor daily I&Os. (D.M) 3. The inability of the skin to lie
flat in original position within 3
Weight on admission seconds is a sign of dehydration.
365lb and 11.2oz (Taber’s 23 p. 632)
365lb and 3oz today
4. Weights should be measured at
the same time of the day every
Daily I&Os day. Insufficient fluid = rapid
Kristopher Kirby 09/28/2020

09/25 09/26 09/27

I-1155 I-6901 I-3296
o- o-5251 o-3450

VS
weight loss. (Tabers 23. p 632
09/2 09/2 09/2
6 7 8 6. Monitor Intake and output and
HR 70 64 63 carefully regulate intravenous
BP 90 108 121 infusions. (Teas p. 1470)
52 65 50
RR 16 16 18
TP 98.6 98.7 97.9
O2 97 97 99

*Additional comments regarding evaluation