Global City Innovative College

College of Nursing and International Health Studies, Fort Bonifacio, Taguig City
Nursing Care Plan
Submitted by: Belleza, Mark Paolo V.
Assessmen Diagnosis Analysis Planning Interventio Rationale Evalutaion
t n
Subjective: Fluid Decrease in After 8 Independent: After 8
Madalas volume fluid intakehours of Monitor CVP hours of
umihi si lola deficit nursing vital signs measurement nursing
pero konti related to intervention, and CVP. s are useful in intervention,
Note determining
lang siya active fluid Increase in patient will goal was
presence/ degree of
uminom ng loss and sodium be able to fluid deficit
partially met
degree of
tubig as decreased maintain postural BP and response as evidenced
verbalized by fluid intake fluid volume changes. to by patient
the patients as evidenced Loss of at a Observe replacement being able to
relative. by water functional for therapy. Fever increase
generalized level as fever. increases urinary
Objective: body evidenced metabolism output and
V/S: weakness Isotonic fluid
by and moist
T 36.5c deficit inindividually exacerbates mucous
P 91 bpm ECF adequate fluid loss. membranes.
R 23 cpm compartmen urinary Patient still
Monitor Fluid
BP 100/70 t output with replacement experiences
urinary
mmhg normal output. needs are episodes of
specific Measure/es based on tachycardia
Generaliz Dehydration gravity, timate fluid correction of and
ed body stable vital losses from current shortness of
weakness signs, moist all sources. deficits and breath.
Episodes Hypovolemia mucous ongoing
of membranes Palpate losses.
shortness and good peripheral
Generalized skin turgor. pulses; Conditions
of breath that
note
 Dry oral body capillary contribute to
mucosa weakness, refill, skin extracellular
Decrease shortness of color/temp fluid deficit
breath, erature. can result in
d skin
Assess inadequate
turgor decreased
mentation. organ
skin turgor perfusion to
Turn all areas and
frequently, may cause
massage circulatory
skin, and collapse/shoc
protect k.
bony Tissues are
prominenc susceptible to
es. breakdown
because of
Dependent: vasoconstricti
Administer on and
IV increased
solutions cellular
as fragility.
indicated:
Isotonic Crystalloids
solutions provide
such as prompt
0.9% NaCl circulatory
(normal improvement,
saline), 5% although the
dextrose/w benefit may
ater be transient
(increased
Administer renal
sodium clearance).
bicarbonat
e, if May be given
indicated. to correct
 severe
Collaborati acidosis while
ve: correcting
Monitor fluid balance.
laboratory
studies as
indicated To assist with
(electrolyte identification/
s, glucose, treatment of
pH/Pco2, underlying
coagulation cause.
studies.)