PILAR

COLLEGE OF ZAMBOANGA CITY, INC.

R.T. Lim Boulevard, Zamboanga City
Tertiary Education Department Nursing Program
NURSING CARE PLAN (NCP)
Name of Student: Date: _________________

Assessment Nursing Diagnosis Planning Implementation Evaluation

Subjective cues: Excess fluid volume Goal of Care: Nsg. Intervention w/ Rationale:
N/A Demonstrate
stabilized fluid Measure I&O, weigh daily, and Measured I&O, weigh daily, and note gain of
Objective cues: volume, with note gain of more than 0.5 more than 0.5 kg/day.
Jaundice balanced I&O, stable kg/day.
Ascites weight, vital signs R To assess circulating volume Auscultated lungs, noting diminished breath Demonstrate stabilized
Bilateral fluid icterus within patient’s status, developing or resolution sounds and developing adventitious sounds. fluid volume, with
Acetaminophen 430 normal range, and of fluid shifts, and response to balanced I&O, stable
ug/ml absence of ascites therapeutic regimen. Measure abdominal girth weight, vital signs
Ast 2094 u/l within patient’s normal
Alt 1685 u/l Auscultate lungs, noting range, and absence of
Bilirubin 0.4 mg/dl diminished breath sounds and ascites
Sodium 146 mmol/l developing adventitious sounds.
R to indicate pulmonary
congestion

Measure abdominal girth.

R to monitor progress of ascites

Administer salt-free
albumin/plasma expanders as
indicated.
To decrease formation of ascites

Administer medications as
indicated
R to increase cardiac
output/improve renal blood flow
and function, thereby reducing
excess fluid.
Checked by: ___________________________________________ Shown to me: _______________________________________
Name and Signature of Clinical Instructor Name and Signature of BSN Student