Nursing Care Plan

Cues and evidences Nursing diagnosis Objectives Interventions Rationale Evaluation

Subjective: Fluid Volume Deficit Within my 8 hrs of Independent: After my 8 hrs nursing care, the
related to active fluid nursing care, the client goal is partially met as evidence
Client verbalized “ volume loss as will be able to relieve  Observe skin or mucuos  Hypovolemia, fluid shifts by:
nakakaon kog cake na evidenced by from pain and maintain membrane dryness and and nutritional deficits
pan.os dayun ning excessive vomiting hydration as evidence turgor contribute to poor skin
sakit akoang tiyan og and diarrhea. by:
sege na dayun kog  Monitor intake and output  Monitoring of output  Heent is normal
suka suka duwa ka  Heent will be helps determine whether
adlaw” normal there is adequate output
of urine as well as normal  The patient is able to maintain
Objective:  The patient is able to defecation hydration
maintain hydration
 Heent : sunken  Encourage the patient to  Advice to increase fluid  Fair skin turgor
eyeballs, dry mouth increase his fluid intake intake is a frequent
 Fair skin turgor
 Pale and weak with atleast 2000L of treatment
 Vomits 4 to 5 times  The patient can go clear liquids. recommendation.  The patient can go back to his
a day back to his normal life Attributed benefits of normal life functioning.
 500ml of yellowish functioning. fluids include replacing
vomitus with small increased insensible fluid
food particles losses, correcting  Improved color and
 Improve color and
 Defecates 5 to 6 dehydration from reduced consistency of the stool
consistency of the
times a day with intake and reducing the
stool
minimal amount of viscosity of mucus.  Decreased frequency of
watery stool. However, there are vomiting
 Decrease frequency of
theoretical reasons for
vomiting
increased fluid intake to
cause harm.

 Advice patient to limit  Rest decreases intestinal

activities and promote motility and reduces
bed rest metabolic rate

 Observe and record stool  Helps differentiate

frequency, characteristics, individual disease and
amount and precipitating assesses severity of
factors . episode
 Eliminate smells from the
environment
 Avoid foods that might
cause or exacerbate
abdominal cramping like
caffeinated beverages,
chocolate, orange juice
and others that precipitate
diarrhea.
Dependent :
 Administer IV Fluids and
medications as ordered:
Pain reliever PRN
PNSS 1L at 22 gtts/min
 Reduces gastric
stimulation and vomiting
response
 Might increase
abdominal cramping
 Medicines are chemicals
or compounds used to
cure, halt, or prevent
disease; ease symptoms;
or help in the diagnosis
of illness