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‌ NURSING‌‌‌CARE‌‌‌PLAN‌‌ ‌

Name of Patient: Mr. Hulu Age: 42 y.o Status: Single Address: Date of Admission: Nov. 16, 1997
Ward: Surgical Bed No. 3
Impression: Stage 3 burn wounds on his anterior and posterior torso and entire left arm with stage 2 burns on his anterior neck
ASSESSMENT PLANNING INTERVENTIONS
PROBLEM CUES/ BEHAVIORAL
RATIONALE OF DESIRED NURSING
NURSING OUTCOME(S) RATIONALE EVALUATION
THE PROBLEM OUTCOME(S) INTERVENTIONS
DIAGNOSIS
Subjective data: Fluid volume After 3 days of After 8 hours of Independent Nursing Desired Outcome.
 Patient states that deficit (FVD) or nursing nursing-patient Interventions: Goal partially met.
“he feels dizzy and hypovolemia is a interventions, the interaction, the patient  Monitor pulse,  Vital sign changes Patients’ vital signs
very week” state or condition patient will be able will be able to: respiration, and seen with fluid starts to normalize
Objective data: where the fluid to normalize  Explain measures blood pressure of volume deficit but the patient still
 Stage 3 burn output exceeds the systolic BP greater that can be taken clients with deficient include needs to achieve
wounds fluid intake. It occurs than or equal to 90 to treat or prevent fluid volume every tachycardia, urine output greater
 Stridor were heard when the body loses mmHg, absence of fluid volume loss. 15 minutes to 1 tachypnea, than 30 mL/hr.
bilateral upon both water orthostasis, HR 60  Patient verbalizes hour for the decreased pulse
auscultation and electrolytes fro to 100 beats per awareness of unstable client and pressure first, then Behavioral
 Thread pulses in m the ECF in similar minute, and urine causative factors every 4 hours for hypotension, Outcome. Goal
all four extremities proportions.  output greater than and behaviors the stable client. decreased pulse Met. Patient was
 Unable to move 30 mL/hr. essential to correct volume, and able to explain
left arm and upper fluid deficit. increased or measures to
body  Patient describes decreased body prevent fluid loss,
Vital Signs: symptoms that  Provide comfortable temperature. verbalize
Temp- 35.9°C indicate the need environment by  Drop situations awareness of
PR- 130 bpm to consult with a covering patient where patient can causative factors
BP- 90/50 mmHg health care with light sheets. experience and behaviors
Urine Output: 20 ml/hr provider. overheating to essential to correct
O2 sat: 92% prevent further fluid deficit, and
Nursing Dx:  Monitor central fluid loss. describe symptoms
 Fluid Volume venous pressure  Hemodynamic that indicate the
Deficit relating to (CVP), pulmonary pressures such as need to consult with
active fluid loss as artery pressure, or CVP and a health care
evidenced by urine stroke volume for pulmonary artery provider.
output of 20 ml/hr, decreasing trends pressures have
heart rate of 130 for more accurate been
beats per minute, fluid volume status. demonstrated to
blood pressure of be less to predict
90/50 mmHg, and fluid volume
temperature of responsiveness,
35.9°C. whereas changes
in stroke volume
measured by a
number of
noninvasive
methods including
passive leg lift may
more accurately
predict fluid
 Monitor serum and volume
urine osmolality responsiveness of
blood urea nitrogen a client.
(BUN)/creatinine  These are all
ratio, and measures of
hematocrit for concentration and
elevations. will be elevated
with decreased
 Educate patient intravascular
about possible volume.
cause and effect of  Enough knowledge
fluid losses or aids the patient to
decreased fluid take part in his or
intake. her plan of care.

Dependent Nursing
Interventions:
 Administer
parenteral fluids as  Fluids are
prescribed. necessary to
Consider the need maintain hydration
for an IV fluid status.
challenge with Determination of
immediate infusion the type and
of fluids for patients amount of fluid to
with abnormal vital be replaced and
signs. infusion rates will
vary depending on
clinical status.
 When ordered,  A fluid challenge
initiate a fluid can help the client
challenge of with deficient fluid
crystalloids for volume regain
replacement of intravascular
intravascular volume quickly, but
volume; monitor the the client must be
client’s response to carefully observed
prescribed fluid to ensure that he
therapy and fluid or she does not go
challenge, into fluid volume
especially noting overload in that
vital signs, urine excess fluid
output, blood volume can lead to
lactate organ edema and
concentrations, and increased
lung sounds. mortality.
 Consult provider if  Prolonged deficient
signs and fluid volume
symptoms of increases the risk
deficient fluid for development of
volume persist or complications,
worsen. including decrease
in cognitive
 function,
weakness,
tachycardia,
hemodynamic
instability, and
kidney injury.
 Maintain IV flow  Fluid overload
rate. Stop or delay require immediate
the infusion if signs attention.
of fluid overload
transpire, refer to
physician
respectively.
Collaborative Nursing
Interventions:
 Hydrate the client  For clients with
with ordered mild to moderate
isotonic IV solutions fluid deficit,
if prescribed. crystalloids such
as 0.9 saline or
lactated Ringer’s
should be used for
fluid volume
 Educate patient replacement.
about possible  Enough knowledge
cause and effect of aids the patient to
fluid losses or take part in his or
decreased fluid her plan of care.
intake.