Saint Paul University Philippines

Tuguegarao City, Cagayan 3500

School of Nursing and Allied Health Sciences

College of Nursing

NURSING CARE PLAN

NCP #3
ASSESSMENT NURSING BACKGROUND GOAL AND NURSING INTERVENTIONS EVALUATION
/ DIAGNOSIS KNOWLEDGE OBJECTIVES AND RATIONALE
CUES
Objective: Fluid Volume Deficient Fluid Volume is a NOC: Hydration NIC: Hypovolemia Management
Deficit decreased intravascular,
interstitial, and/or Long Term Goal: Long Term Goal:
Vital signs:
intracellular fluid. This - After 2 hours of - After 2 hours of
BP - 90/60
HR – 130 refers to dehydration and nursing intervention, nursing intervention,
the patient will be able the patient was able to
RR – 27 water loss alone without
to maintain fluid maintain fluid volume
Temp. – 38.2. a change in sodium.
volume at a functional at a functional level as
th
(Nanda,15 edition) level as evidenced by evidenced by
SpO2 60%
individually adequate individually adequate
Deficient Fluid urinary output with urinary output with
ABG result: Volume (also known as normal specific gravity, normal specific
pH-7.6, Fluid Volume Deficit stable vital signs, moist gravity, stable vital
PaO2-120 (FVD), hypovolemia) is a mucous membranes, signs, moist mucous
mmHg, state or condition where good skin turgor, membranes, good skin
PaCO2 - 31 the fluid output exceeds prompt capillary refill, turgor, prompt
mmHg, and the fluid intake. It occurs and resolution of capillary refill, and
HCO3 - 25 when the body loses both edema. resolution of edema.
mmol/L water Short Term Goal:
and electrolytes from the
After 1 hour of
ECF in similar
nursing intervention,
Subjective: N/A proportions. Short Term Goal:
the patient was able
(Nurseslabs.com) After 1 hour of nursing to:
intervention, the patient
will be able to:
1. Maintain vital
 Monitor and document vital signs and there
1. Maintain a were no
signs, especially BP and HR.
normal vital A decrease in circulating abnormal vital
sign. blood volume can cause signs reported.
hypotension and tachycardia.
Alteration in HR is a
compensatory mechanism to
maintain cardiac output.
Usually, the pulse is weak and
irregular if electrolyte
imbalance also occurs.
Hypotension is evident in
hypovolemia.

2. Have a normal
body
 Monitor and document temperature of
temperature. 36.1°C to
Febrile states decrease body 37.2°C.
fluids by perspiration and
increased respiration. This is
known as insensible water 3. Monitor
 loss. ABG’s and the
client
 Monitor ABGs for changes to maintains
prevent respiratory failure. ABGs and
Oxygen saturation should be normal oxygen
kept at 90% or greater saturation of
(preferably 94% or higher, but 95%-100%
this will depend on the
patient’s medical history).