Bicol University Tabaco Campus

Nursing Department
Tabaco City

Nursing Care Plan

Planning Intervention
Date/ Dependent/ Rationale
Assessment Nursing Diagnosis Desired/Expected Evaluate
Time Goal Independent/
Outcome
Collaborative
After 24 hours of After 42 hours of
Sept. Subjective: nursing intervention nursing The goal is met
10, Ms. Marilyn reports the patient has; intervention the after 24 hours of
2021 “weakness, malaise, patient; nursing
3:00 and flu-like intervention.
PM symptoms for 3-4 #1 Deficient Fluid Volume -Adequate fluid -Vital signs independent The goal is met
days. Nausea, Related to vomiting volume intake remain intervention after 24 hours of
vomiting, and liquid Normal - Small frequent - Avoids vomiting nursing
stools 2-4 times a -Has no sign and eating intervention.
day”. symptoms of Dependent
dehydration intervention
Objective: - Monitoring IV line - Avoids fluid overload
-Height: 160 cm for proper fluid or dehydration
(5’3”) infusion and
-Weight: 66.2 kg monitor input and
(146 lb) output
-BP: 102/84mmHg Collaborative - Promotes faster
-RR: 24 CPM intervention recovery of the patient
-PR: 86 BPM - Give medication
-Mild fever: 38.6°C as prescribe by
(101.5°F) physician
-Scant urine output
-Dry oral mucosa, #2 Activity tolerance related - independent
furrowed tongue, to physical weakness. intervention
and cracked lips Inability to tolerate fluid
-Urine specific - The pt. is advice to - Avoids vomiting
gravity: 1.035 drink fluids as
tolerated - Promotes mobility
-Serum sodium: 155 - Promote active
mEq/L range of motion
-Serum Potassium: exercises
3.2 mEq/L
-Chest x-ray: Dependent
Negative intervention - Promotes mobility
- Assist in passive
range of motion
exercises
Collaborative - Avoids fluid overload
intervention
- Adjust IV fluid
infusion as
Ordered - Promotes faster
- Give medication recovery of the patient
as prescribe by
physician

#3 Fluid and Electrolyte - Increase of -Vital signs independent

Imbalances r/t AEB serum remain intervention
Hypokalemia (serum Potassium Normal - The patient is - Promote proper diet
potassium level below 3.5 - Improvement in -Has no sign and advised to eat food
mEq /L.), high specific Fluid and symptoms of rich in potassium
gravity. electrolyte Hypokalemia and Dependent
imbalance Fluid and intervention
- To monitor progress
electrolyte - Monitor input and
of fluid and
imbalance output
electrolyte imbalance
- Monitor for any
signs of
progressive fluid
and electrolyte
imbalance
#4 Impaired Skin Integrity -
r/t over/ covert cues on skin
assessment.

#5 Risk for Decreased -

cardiac output related to
Fluid And Electrolyte
Imbalances + Over/covert
cues.

#6 Risk for ineffective -

tissue perfusion related to
Fluid And Electrolyte
Imbalances + Over/covert
cues.