XV.

NURSING CARE PLAN CHRIST THE KING COLLEGE

Magsaysay Blvd, Calbayog City
COLLEGE OF NURSING

NURSING NURSING
CUES DIAGNOSIS RATIONALE PLANNING INTERVENTIONS RATIONALE EVALUATION

Subjective Cues: Risk for Deficient The patient is risk for After 8 hours of Provide oral fluids as Distribute the amount of After 8 hours of Nursing
As verbalized by Fluid Volume deficient fluid volume Nursing Interventions prescribed throughout the fluids throughout the Interventions the patient;
the patient’s Related to results from a loss of the patient will; day. entire day.
mother; Decreased Food body fluid due to Identified the risks
and Water Intake as vomiting and less fluid Identify individual risk Ask about oral fluid Patients are more likely factors and appropriate
“Nagsusuka siya Evidenced by intake causing the factors and preferences and provide to increase their fluid interventions for fluid
pati karon” Vomiting. fluid output to surpass appropriate preferred fluids within the intake if they like the volume deficient.
“Kaduha nagsuka fluid intake. interventions. ordered restriction. flavor and temperature of
ron” the beverage. Maintained fluid volume
“Gabie kaduha Maintain fluid volume as evidenced by
nagsuka” at a functional level as Place the beverage within Fluids within the patient’s adequate output of urine,
“Paggakaon siya evidenced by view and close reach at visual field serve as a stable vital signs, good
iya lang gakasuka” adequate urinary the bedside table. constant reminder to skin turgor and prompt
“5 days siya nag output, stable vital take in fluids. capillary refill.
suka sakit ang ulo signs, good skin
bago namo gi turgor and prompt Administer appropriate Administer the Demonstrated behaviors
admit ngari” capillary refill. medication as ordered. antipyretics and to prevent development
antiemetics drugs to of fluid volume deficit.
Objective Cues: Demonstrate the reduce fluid loss, if the
Weak proper behaviors to patient experiences The goal met.
Sleeping prevent development vomiting.
of fluid volume deficit. Avoid caffeine containing
beverages. Caffeine has diuretic
properties and may
contribute to fluid volume
loss and electrolyte
imbalances.