Holy Angel University

NCM 107: Maternal and Child Nursing

S.Y. 2022-2023

Nursing Care Plan

Assessment Nursing Diagnosis Scientific Objectives Interventions Rationale Evaluation

Explanation
S > the patient Patients with severe Short term: ● A decrease in Goal Met:
verbalized “ nanghihina Deficient Fluid dengue present After 8 hours of nursing ● Monitor and circulating blood The patient will be free
po ako” Volume rt insufficient severe dehydration interventions, the client document vital volume can cause from signs of deficient
fluid intake because of massive will be able to signs, especially hypotension and fluid volume and will be
O> secondary to dengue bleeding, plasma BP and HR. tachycardia. able to restore fluid
- Poor skin turgor aeb poor skin turgor, leakage through the 1. verbalize Alteration in HR is a balance.
- Dry skin and lips dry skin, weakness vessel wall leading to awareness of causative compensatory
- Pale pink mucosa appearance, water movement factors of deficient fluid mechanism to Goal Partially Met:
- The patient appeared persistent vomiting, which can lead to volume and explains maintain cardiac The patient still
to be weak 3 seconds capillary large amount of measures that can be output. Usually, the manifests signs of
- Persistent vomiting refill and patient water loss in the taken to treat and pulse is weak and deficient fluid volume
- 3 seconds capillary verbalization circulatory system prevent fluid volume irregular if but will be able to
refill loss electrolyte restore fluid balance.
imbalance also
Long term: occurs. Goal Unmet:
After 3 days of nursing Hypotension is The patient still
interventions, the client evident in manifests signs of
will be able to meet the hypovolemia deficient fluid volume
fluid volume and will not be able to
requirements and ● To assess their restore fluid balance.
● Monitor I & O
become free from any hydration status and
signs of fluid deficit determine the need
for additional fluids

● Oral fluid
● Urge to patient to replacement is
drink the prescribed indicated for mild
amount of fluid fluid deficit and is a
 Holy Angel University
NCM 107: Maternal and Child Nursing
S.Y. 2022-2023

Nursing Care Plan

cost-effective Goal Met:
method for Patient verbalized
replacement awareness of causative
treatment factors of deficient fluid
volume and explains
● Emphasize the ● A fluid deficit can measures that can be
cause a dry, sticky taken to treat and
importance of oral
mouth. Attention to prevent fluid volume
hygiene
mouth care loss
promotes interest in
drinking and Goal Partially Met:
reduces the Patient verbalized
discomfort of dry awareness of causative
mucous factors of deficient fluid
membranes volume but did not
explain measures that
can be taken to treat
● Administer ● Fluids are and prevent fluid
parenteral fluids as necessary to volume loss
prescribed maintain hydration
status. Goal Unmet:
Determination of the Patient did not
type and amount of verbalize awareness of
fluid to be replaced causative factors of
and infusion rates deficient fluid volume
will vary depending and did not explained
on clinical status. measures that can be
taken to treat and
prevent fluid volume
loss
 Holy Angel University
NCM 107: Maternal and Child Nursing
S.Y. 2022-2023

Nursing Care Plan

● Educate the patient ● Enough knowledge

about the possible aids the patient in
causes and effects taking part in their
of fluid loss or plan of care
decreased fluid
intake

● Emphasize the ● Increasing the

patient’s knowledge
relevance of
level will assist in
maintaining proper
preventing and
nutrition and managing the
hydration problem