ST.

ANTHONY’S COLLEGE
Nursing Department

NURSING CARE PLAN

Name of patient: M. F_________ Attending Physician: _____________________________
Age: __87 years old___ Ward/Bed #: _Emergency Department____ Impression Diagnosis: _Fluid Volume Imbalance________

Clustered Cues: Nursing Diagnosis Rationale Outcome Criteria Nursing Interventions Rationale Evaluation

Fluid volume deficit Continuous vomiting and After 4 hours of  Monitor and  Decrease in At the end of
Subjective Data: related to Vomiting diarrhea may result to nursing Intervention document vital circulating blood nursing
and Diarrhea dehydration due to loss of the patient will be: signs especially volume can cause interventions, the
“Her spouse states fluid in the body and its BP and HR. hypotension and client is able to:
she had been inability to reciprocate  tachycardia.
slightly confused the loss fluid as evidence normovolemi Alteration in HR is a Be normovolemic as
for the past 12 by the patient has not compensatory evidenced by
c as
hours” been able to eat for 24 mechanism to normal blood
hours and appears to be evidenced by maintain cardiac pressure, heart rate,
“She has been lethargic and slightly systolic BP output. Usually, the urine output, and
vomiting and had confused for the past 12 greater than pulse is weak and skin turgor.
diarrhea for the hours. or equal to 90 may be irregular if
past 24 hours as mm HG and electrolyte Observe lifestyle
verbalized by the imbalance also changes to avoid
patient” HR of 60 to occurs. progression of
100 dehydration as
“She initially beats/min,  Assess  Alteration in evidenced by her
stated of decrease urine output patient’s mentation/sensorium statement that she’ll
of taste and smell” greater than orientation may be caused maintain fluid
electrolyte intake.
30 mL/hr,
Objective Data: abnormalities
normal lab Enumerate at least 3
Patient has Unable results and  Assess color  A normal urine ways of correcting
to eat for 24 hours normal skin and amount of output is considered fluid deficits.
turgor. urine. Report normal not less than
Decrease oral urine input and 30ml/hour. Enumerate at least 3
intake  Patient output less than Concentrated urine ways of preventing
demonstrate 30 ml/hr for 2 denotes fluid deficit. fluid volume loss.
Patient appears s lifestyle consecutive
increasingly changes to hours. Feel better,
lethargic  Auscultate and  Cardiac alterations comfortable, and
avoid
document heart like dysrhythmias oriented as
Vital Signs: progression sounds; note may reflect evidenced by her
of rate, rhythm or hypovolemia and/or good status,
T = 37.5 C dehydration. other abnormal electrolyte appearance, and
HR=102 bpm findings. imbalance. response to
RR= 22 cpm  Patient interventions.
BP= 100/ 68 bp verbalizes
O2 sat= 95 % awareness of  Monitor lab  Elevated blood urea
causative results such nitrogen suggests
fluid deficit. Urine
factors and as serum
specific gravity is
behaviors electrolytes likewise increased.
essential to and urine
correct fluid osmolality,
deficit. and report
abnormal  Prevent situations
 Patient where patient can
values. experience
explains
 Provide overheating to
measures comfortable prevent further fluid
that can be environment by loss.
taken to treat covering  For Fluid
or prevent patient with replacement
fluid volume light sheets.
 Administer
loss. parental fluids  Maintain IV flow
 Patient as prescribed rate. Stop or delay
by the doctor the infusion if signs
describes
 Maintain IV of fluid overload
symptoms flow rate. Stop transpire, refer to
that indicate or delay the physician
the need to infusion if respectively.
consult with signs of fluid
overload
health care
transpire, refer  Fluid losses from
provider. to physician diarrhea should be
  Patient is respectively. concomitantly
comfortable  Provide treated with
measures to antidiarrheal
and oriented.
prevent medications, as
excessive prescribed.
electrolyte loss Antipyretics can
like resting the decrease fever and
GI tract, fluid losses from
administering diaphoresis.
antipyretics as  Educate patient
ordered by the about possible cause
physician. and effect of fluid
 Educate patient losses or decreased
about possible fluid intake.
cause and
effect of fluid
losses or  Increasing the
decreased fluid patient’s knowledge
intake. level will assist in
 Emphasize the preventing and
relevance of managing the
maintaining problem.
proper nutrition
and hydration.  An accurate measure
of fluid intake and
output is an
 Teach family important indicator
members how of patient’s fluid
to monitor status.
output in the
home. Instruct
them to
monitor both
intake and
output.
Student’s Name: __TRAIN, TIRON, TUMANGDAY____________
Clinical Instructor: __Mrs. Maria Janice R. Magluyan, RN___________________