NCP

ASSESSMENT/DATA NURSING OUTCOMES IMPLEMENTATI RATIONALE EVALUATION

DIAGNOSIS ON

Subjective: ✓ Risk for Short term goal: 1. Monitor vital - Blood pressure, heart - After rendering 1
imbalance signs. rate and respiratory hour nursing
"Mal-ul-ulawah ngay fluid volume - At the end of 1 rate often increase implementation the
ya mun kakapsuta", as secondary hour, the patient initially when either patient was able to
verbalized by the to will be able to fluid deficit or excess is verbalize the
patient. decreased verbalize the present. understanding
cardiac understanding about the
output. about the preventive
preventive measures on
Objective:
measures on increasing and
BP: 160/90 mmHg increasing and decreasing fluid
decreasing fluid intake. Goal met.
PR: 92bpm intake.

RR: 25bpm - This may indicate

2. Monitor urine deficient fluid volume - At the end of 8
Long term goal: hours the patient
output hourly or or cardiac or kidney
as needed. failure. was able to
- At the end of 8
Report urine demonstrate
hours the patient
output less than adequate fluid
will be able to
30ml/hr or balance as
demonstrate
0.5ml/kg/hr. evidenced by stable
adequate fluid
vital signs, palpable
balance as
pulses of good
evidenced by
quality, and
stable vital signs, 3. Measure or individual
palpable pulses of weigh diapers - To evaluate if there is appropriate urinary
good quality, and and continence excessive bleeding. output. Goal met.
individual pads, when
appropriate urinary indicated.
output.
4. Discuss
individual risk
- To prevent or limit
factors or
fluid imbalance and
potential
complications.
problems and
specific
intervention.