LACANLALE, KRISTLE ANNE F.

BSN 1Y-2-IRR 1 GROUP 2

Nursing Care Plan
(ADPIE)

Case : Mia Khalifa, a 35 yr old sales lady, reports weakness, and flu-like symptoms for 3-4 days. Although thirsty, she is unable to tolerate fluids because of nausea and vomiting,
and she has liquid stools 2-4 times per day.

ASSESSMENT DIAGNOSIS PLANNING INTERVENTION EVALUATION

Subjective: Risk for Deficient Fluid Volume After 8 hours of nursing 1. Assess the patient's vital signs and After 4 hours of nursing
2-4x loose stools related to nausea, vomiting, and interventions, will maintain an condition, ask her to verbalize how interventions, the patient was able
Flu-like symptoms diarrhea as evidenced by decrease adequate fluid volume by she feel physically. to achieved normal vital signs and
(+) nausea fluid intake and high results of increasing fluid intake and will be maintained an adequate fluid
(+) Vomiting Diagnostic test. aware of the importance of 2. check signs of dehydration by skin volume by increased fluid intake.
(+) Decrease fluid intake hydration in her body. turgor, skin color and eye area's
color.
Objective:
Ht. : 5'3 3. Ensure accurate intake and output
Wt. : 166 lbs monitoring.
T : 38.6
PR : 86 BPM 4. Encourage increase fluid intake
RR : 24 CPM providing appealing liquids.
BP : 130/90
5. Encourage patient to eat foods
Focus: that is rich in potassium (e.g. banana)
Urine Specific gravity : 1.0357
Serum sodium : 155 meq/L 6. Encourage to avoid food that
cause dehydration such as coffee,
tea and dairy.

7. Administer ORS or Loperamide for

diarrhea as ordered by physician.
 Nursing Care Plan
(ADPIE)

ASSESSMENT DIAGNOSIS PLANNING INTERVENTION EVALUATION

Subjective: Hyperthermia related to the patient’s After 4 hrs. Of nursing 1. Monitor the patient's vital signs After 4 hrs. of nursing interventions,
2-4x loose stools condition manifested by increased of interventions, the patient will able every 4 hrs. and ask her to verbalize the patient was able
Flu-like symptoms body temperature. to maintain core temperature how she feel physically. maintain core temperature within
(+) nausea within normal range and achieve normal range and achieved normal
(+) Vomiting normal vital signs. 2. Encourage increase fluid intake. vital signs.
(+) Decrease fluid intake
3. Promote surface cooling by means
Objective: of tepid sponge bath.
Ht. : 5'3
Wt. : 166 lbs 4.Adjust and monitor environmental
T : 38.6 factors like room temperature and
PR : 86 BPM bed linens as indicated.
RR : 24 CPM
BP : 130/90 5. Eliminate excess clothing and
covers.

Urine Specific gravity : 1.0357 6. Administer antipyretics

Serum sodium : 155 meq/L as prescribed by the physician.

Focus: 7. Wash hands with antibacterial

Temp.: 38.6 soap before and after each care
of activity and encourage proper
hygiene.
SOAPIE

S – Patient reports weakness

- 3-4 days Flu- like symptoms
- Thirsty
- nausea and vomiting
- liquid stools 2-4 times a day
O – T: 38.6
- PR: 86 BPM
- RR: 24 CPM
- BP: 130/90
- Urine Specific Gravity – 1.0357
- Serum sodium – 155 meq/L
A – Deficient fluid Volume related to Active Fluid loss and inadequate Fluid intake caused by diarrhea, nausea and vomiting.
P - Patient will be able to maintain an adequate fluid intake and will prevent fluid active loss.
I - Urge patient to drink prescribed amount of fluid
- Administer Loperamide or ORS for Diarrhea as ordered by physician.
- Monitor fluid Intake and Output.
E – Patient was able to maintain an increased fluid intake and able to explain measures that can be taken to treat or prevent fluid loss.
FDAR

F – Deficient fluid volume

D – Patient reports weakness, flu- like symptoms for 3-4 days, unable to tolerate
liquids due to nausea and vomiting, loose stools 2-4 times a day. T: 38.6, PR: 86
BPM, RR: 24 CPM, BP: 130/90. Urine specific gravity: 1.0357, Serum sodium:
155meq/L
A – Encouraged to drink an adequate amount of liquid; Administered medications
as ordered by physician; Monitored vital signs, fluid intake and output.
R – Able to maintain fluid volume at functional level with good skin turgor and
normal vitals signs.