NURSING CARE PLAN

ASSESSMENT NURSING EXPECTED PLANNING/ RATIONALE EVALUATION

DIAGNOSIS OUTCOME INTERVENTION
SUBJECTIVE DATA The patient is This fundamental 1. Maintain regular oral 1. Due to fluid loss in Outcomes have been
The patient reports feverish. balance, as shown by hygiene. the interstitial spaces, met, and the client
weakness, and flu- Electrolytes in the 2. Weigh yourself every the oral mucous reports that her illness
like symptom for 3-4 blood and muscle day and keep track of membranes become is under control.
days power are not to be trends. dry and sticky.
compromised. 3. When necessary, 2. Weight aids in
OBJECTIVE DATA Deficient Fluid Fluid balance is monitor vital signs. determining fluid
Volume related to demonstrated by 4. Administer IV therapy balance.
Temp: 38.6
PR: 86BPM nausea, vomiting, maintaining the specific as directed. 3. Vital sign changes,
RR: 24CPM
and diarrhea as gravity of urine, the 5. Collect samples for such as an increase in
BP: 130/90
Diagnostic Data evidenced by turgor of the skin, moist potassium level analysis. heart rate or a
Urine specific
decreased urine mucous membranes, potassium levels in decrease in blood
gravity: 1.0357
Serum Sodium: output, increased body temperature, pulse serum and urine as pressure
155meq/ L urine concentration, rate, and blood instructed 4. Hypokalemia is
CXR: negative
weakness, fever, pressure. characterized by low
s
decreased blood pressure and a
skin/tongue turgor, rise in temperature.
dry mucous
membranes,
increased pulse rate,
and decreased blood
pressure

5.Urine analysis
determines whether a
substance was
retained or lost.
sodium and the ability
of the kidneys to
concentrate or dilute
urine
in response to fluid
changes