Aprile Monique Nicolas

BSN 206 Grp. 23

Nursing Care Plan

Assessment Cues Nursing Analysis Goal and Nursing Rationale Evaluation

Diagnosis Objectives Intervention

Subjective Cues: Deficient fluid Infants and Goal:

volume related children have a After 8hours of  Note For baseline Was the client will be
The mother said to diarrhea, relatively high nursing possible data able to maintain fluid
that her child vomiting, percentage of intervention the cause that balance and to prevent
looks weak, and extreme of age, total body water, client will be able may result any further
vomit Gastric are sensitive to to maintain fluid to fluid complication?
intubation loss, and are less balance and to volume
Objective Cues: (OGT) able to control prevent any deficit and Yes ___
 Increased their fluid intake. further other No ___
body It is also cause by complication. factors. Why?
temperat prolonged
ure (37.4) diarrhea and Objectives:  Determine Very young and
 Decrease health problem effects of extremely Was the client able to
d skin that can result to After 10 minutes age elderly assess the causative
turgor active fluid of nursing individual are and precipitating
 Dry skin volume loss. intervention the quickly factors?
 Decrease client will be able affected by
d urine to assess fluid volume Yes ___
output causative and deficit, and are No ___
precipitating least able to Why?
factors. express need.
After 10 minutes  Estimate To know and Was the client will be
of nursing procedural monitor the able to maintain
intervention the losses and fluid that can correct /replace losses
client will be able note be loss. to reverse
to maintain possible pathophysiological
correct /replace routes of mechanisms?
losses to reverse insensible
pathophysiologica fluid losses. Yes ___
l mechanisms No ___
Why?
After 10 minutes
of nursing  Monitor Baseline data
intervention the vital signs
client will be able Was the client will be
to be provided  Monitor Baseline data able to be provided
with comfort and complains and to keep in with comfort and
safety. and track on the safety?
physical condition of
After 10 minutes sign the client Yes ___
of nursing associated No ___
intervention the to Why?
client will be able dehydratio
to promote n.
wellness.
Was the client will be
 Measure When ascites able to promote
abdominal and third wellness?
girth and spacing of fluid
asses for occurs Yes ___
peripheral No ___
edema Why?
 Establish Prevents
24 hours peaks/valleys
fluid in fluid level
replaceme
nt needs
and routes
to be used

 Administer To replace the

IV fluids as loss fluid in the
indicated. body

 Maintain To compute
accurate exactly the loss
I/O and fluid in the
weigh daily body and to
know if it is
within the
normal range.

 Change To promote
position comfort
frequently

 Administer To provide
medication physiological
. comfort to the
client.