STUDENT NURSE’S NAME: Mixcy A.

Mabatid Date: March 8, 2022

Client’s Name: Sandra B. Age: 2 months old

NURSING CARE PLAN

ASSESSMENT NURSING DIAGNOSIS PLANNING INTERVENTIONS RATIONALE EVALUATION

Subjective: The mother Risk for deficient fluid Within 3 hours of nursing 1. Obtain specimens for 1. Urine and serum analysis After 3 hours of nursing intervention
of the patient verbalized volume related to intervention the patient will be able analysis of altered provides information about the patient has been able to
that Sandra breastfed vomiting to tolerated clear liquids without potassium levels as extracellular levels of tolerated clear liquids without
well for the first couple vomiting indicated. potassium. There is no vomiting
of weeks, but since then practical way to measure
“throws up all the time intracellular K.
like she’s forcing all her 2. Administer prescribed 2. Low potassium levels are
feedings out. She looks supplemental potassium dangerous and the patient
skinny and sick, and she (PO, NG, or IV) per policy. may require supplements.
cries and is fussy all the 3. Monitor for neurologic and 3. Potassium is a vital
time.” neuromuscular electrolyte for skeletal and
manifestations of smooth muscle activity.
Objective: hypokalemia.
- 4. Monitor for cardiac 4. Many cardiac rhythm
manifestations of disorders can result from
hypokalemia. hypokalemia. It is critical to
monitor cardiac function
with hypokalemia.

5. Maintain accurate intake 5. Accurate records are critical

and output record. in assessing the patient’s
fluid balance.
6. Monitor vital signs as 6. Vital sign changes such as
appropriate. increased heart rate,
decreased blood pressure,
and increased temperature
indicate hypovolemia.
 7. Give fluids as appropriate.
8. Administer IV therapy as
prescribed.
9. Teach family members how
to monitor output in the
home. Instruct them to
monitor both intake and
output.
10. Identify an emergency plan,
including when to ask for
help.
7. As her nausea decreases
encourage her oral intake of
fluids as tolerated, again to
replace lost volume.
8. She will probably require
intravenous replacement of
fluid. This is especially true
because her oral intake is
limited because of nausea
and vomiting
9. An accurate measure of
fluid intake and output is an
important indicator of
patient’s fluid status.
10. Some complications of
deficient fluid volume
cannot be reversed in the
home and are life-
threatening. Patients
progressing toward
hypovolemic shock will need
emergency care.