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 volume Decrease in After 8 hours Independent: After 8 hours
“Madalas deficit fluid intake of nursing • Monitor CVP of nursing
umihi si lola related to intervention, vital signs measurement intervention,
pero konti active fluid patient will and CVP. s are useful in goal was
Note determining
lang siya loss and Increase in be able to partially met
presence/ degree of fluid
uminom ng decreased sodium maintain deficit and
as evidenced
degree of
tubig” as fluid intake fluid volume postural BP response to by patient
verbalized by as at a changes. replacement being able to
the patient’s evidenced Loss of water functional Observe for therapy. Fever increase
relative. by level as fever. increases urinary
generalized evidenced metabolism output and
Objective: body Isotonic fluid by and moist
V/S: weakness deficit in ECF individually exacerbates mucous
T – 36.5°c compartmen adequate fluid loss. membranes.
P – 91 bpm t urinary Patient still
• Monitor Fluid
R – 23 cpm output with experiences
urinary replacement
BP – 100/70 normal needs are episodes of
output.
mmhg Dehydration specific based on tachycardia
Measure/es
gravity, timate fluid correction of and
• Generaliz stable vital losses from current shortness of
ed body Hypovolemia signs, moist all sources. deficits and breath.
weakness mucous ongoing
• Episodes membranes • Palpate losses.
of Generalized and good peripheral
body skin turgor. pulses; Conditions
shortness
weakness, note that
of breath
capillary contribute to
• Dry oral shortness of refill, skin extracellular
mucosa breath, color/temp fluid deficit
decreased erature. can result in
• Decrease
skin turgor Assess inadequate
d skin mentation. organ
turgor perfusion to
• Turn all areas and
frequently, may cause
massage circulatory
skin, and collapse/shock
protect .
bony Tissues are
prominenc susceptible to
es. breakdown
because of
Dependent: vasoconstricti
• Administer on and
IV solutions increased
as cellular
indicated: fragility.
Isotonic
solutions Crystalloids
such as provide
0.9% NaCl prompt
(normal circulatory
saline), 5% improvement,
dextrose/w although the
ater benefit may
be transient
• Administer (increased
sodium renal
bicarbonat clearance).
e, if
indicated. May be given
to correct
Collaborati severe
 ve: acidosis while
• Monitor correcting
laboratory fluid balance.
studies as
indicated
(electrolyte To assist with
s, glucose, identification/
pH/Pco2, treatment of
coagulation underlying
studies.) cause.