Bicol University Tabaco Campus

NURSING DEPARTMENT

NURSING CARE PLAN (NCP)

Date/ PLANNING
Time Goal INTERVENTION
ASSESSMENT Desired/Expected EVALUATION
Dependent/ Rationale
NURSING Outcome(s) independent/
DIAGNOSIS* Collaborative
December Subjective: Fluid Volume Deficit Short Term: After 36 hours of Independent: -Patients' vital signs The patient had
06,2021 The patient related to nausea and Patients will be nursing interventions, - Examine your vital are checked for already healed,
complains of being vomiting as evidenced by able to do the the patient will regain signs as well as the primary indicators of regained
sick, thirsty, and weakness, dry oral following after 12 condition of your oral
strength and experience their health status, strength, and
unable to drink mucosa, furrowed hours of nursing: mucous membranes.
fluids. tongue, crack lips, less diarrhea. as well as mucous had a normal
- drink enough - It's important to membrane fluid balance in
Objective: liquids to stay keep track of your examination to the body as a
Weak in hydrated without intake and output. ensure correct result of the
-Risk for dry mouth
appearance vomiting dehydration therapy nursing
-Height:160 cm - Encourage more is administered. treatments,
-Risk for deficient fluid - having moist fluid intake, but keep
(5’3”) avoiding further
volume mucosal an eye on nausea
Weight: 66.2 kg membranes in and vomiting. - Monitoring the risk factors.
(146 lb) one's mouth patient's intake will
-Risk for electrolyte
BP:102/84mmH g imbalance help to ensure that
Pulse: 86 bpm Long Term: Collaborative: he or she is getting
Respiration: 24/ After 3 days of -Administered IV enough water and
-Risk for imbalance
nursing solutions (0.45% other nutrients.
min fluid volume
interventions the NaCl) as prescribed..
patient:
 Bicol University Tabaco Campus
NURSING DEPARTMENT

- Demonstrate Dehydration, fluid

optimal hydration retention, and other
and electrolyte fluid-related issues
balance. can be avoided by
keeping an eye on
them.

- Water drinking aids

in the maintenance
of fluid balance in
the body. Because
these variables
influence fluid intake
requirements and
replenishment
methods.

- Can be used to
assist the kidneys
with both
electrolytes and free
water for waste
removal.
 Bicol University Tabaco Campus
NURSING DEPARTMENT

Subjective: Risk for urinary tract Short term: In terms of the Independent: After the
Reports being Infection (UTI) as After 6 hours of infection, the patient -Continue to monitor nursing
weak and malaise. evidenced by urine nursing care, the will regain her strength vital signs. interventions,
specific gravity. patient's physical and return to her The patient had
Objective: appearance will previous state. -Encourage them to already healed
return to normal drink extra water to the point
Scant Urine while keeping an eye where she had
output Long-term: on them for any signs
regained
After 5-7 days of of vomiting.
strength and
Urine Specific nursing had urinalysis in
Gravity: 1.035 intervention, the -Educate people
about the importance her system,
Serum patient is in good which ruled out
of perineal care.
health and shows any additional
Potassium 3.2 no signs of risk factors.
Collaborative:
mEq /L Serum infection.

- Administer
Sodium: 155 mEq/
antibiotics as
L Chest x-ray prescribed by the
negative doctor.
 Bicol University Tabaco Campus
NURSING DEPARTMENT

Subjective: Short term: The patient's strength Independent: -A The vital signs of After the
Reports that she Reduced fluid absorption The patient's will return, and her - Examine the a patient are nursing
has liquids stool as a result of illness, as diarrhea is bowel function will patient's vital signs recorded in order to treatments, the
for 2-4 days alleviated after 5 and condition. obtain important
evidenced by a mild return to normal. goals and
hours of nurse indicators of their
fever and loose stools. health status. expected
Objective: Weak care. - Encourage people outcomes were
in physical to eat bananas. met; the
appearance Long term: - Bananas have a
high potassium diarrhea was
Mild Fever: 38. The patient's stool - Educate people
level, which helps to resolved.
6 °C (101.5 °F) consistency about adequate
restore electrolytes
improved after two perineal care.
lost through sweat.
days of nursing It also contains a lot
intervention.. Collaborative: of fiber, which helps
to bulk up the stool
-Administer and encourages
antidiarrheal regular bowel
medication as movements.
prescribed by your
physician
(Loperamide)

The patient temperature -must be able to After the

and his condition will be determine the nursing
Bicol University Tabaco Campus
NURSING DEPARTMENT

back to normal patient's exact intervention, the

temperature in order patient's
to assess his or her temperature
health returned to
-this will assist in the normal, with no
cooling down of the more difficulties,
Shivering can be suggesting that
caused by the the goal and
patient's body expected result
temperature and were met.
alcohol use.

- Assisting the
patient or guardian
in orienting
themselves and
offering comfort

- keeping an eye on
these can help you
figure out whether
the patient has any
worries.

- paracetamol is
used to lower a high
fever and
Ceftriaxone is used
to treat a bacterial
infection
 Bicol University Tabaco Campus
NURSING DEPARTMENT

*In writing your Diagnostic Statement, please follow the P.E.S. format but, if S/S is already included in the ASSESSMENT column, then write only the P.E.
format. If “RISK diagnoses,” identify what the client would exhibit (Note: there are no S/S for “RISK” problems/diagnosis).

CLINICAL INSTRUCTOR’S REMARKS/COMMENTS:

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