NURSING CARE PLAN

CUES NURSING RATIONALE GOAL/OBJECTIVE INTERVENTION RATIONALE EVALUATION

DIAGNOSIS
OBJECTIVE: P- Fluid Fluid volume SHORT TERM: INDEPENDENT: SHORT TERM:
Volume deficit deficit occurs After 3 to 4 After 3 to 4
>Decreased from a loss hours of nursing -Encourage -To have hours of nursing
urine output. E-related to of body fluid intervention, the patient to drink adequate urine intervention, the
output.
(160 cc for the abnormal fluid or the shift of patient will be able plenty of fluids. patient was able
whole shift) loss (vomiting). fluids into to: to:
the third -Bathe less -To maintain
>Dry skin S-as space, or -Will have adequate frequently using skin integrity -Have adequate
manifested by: from a urine output of 20cc mild cleanser / and prevent urine output.
excessive
>Decrease reduced fluid to 30cc / hr. soap and provide dryness.
From 20cc to
skin turgor / >Decreased intake. optimal skin care 30cc / hr. (250cc
mucous urine output. Common -Have balance with suitable for the whole
membranes (150 cc for the sources for intake and output emollients. shift)
whole shift) fluid loss are over 24 hours.
>Increased the -Provide frequent -To prevent -Have balance
body >Dry skin gastrointesti LONG TERM: oral, eye care injury from intake and output
temperature nal (GI) tract, After 1 to 2 hours dryness over 24 hours.
(37.9oC) and >Decrease polyuria, and of nursing DEPENDENT:
BP (130/90 ) skin turgor / increased intervention, the LONG TERM:
mucous perspiration. patient will be able -Administer IVF - To prevent After 1 to 2
membranes Fluid volume to: as prescribed by valley in fluid hours of nursing
SUBJECTIVE: deficit may the physician. level. intervention, the
“Nag suka >Increased be an acute -Will have good skin patient was able
ako ng mga 3 body or chronic turgor. to:
beses. temperature condition
Sinuka ko (37.9oC) and managed in -Exhibit good -Have good skin
yung mga BP (130/90 ) the hospital, hydration (moist turgor.
kinain ko.” outpatient mucous
>Patient’s membranes, ability -Exhibited good
center, or
verbalization to perspire) hydration (moist
home
of: “Nag suka mucous
setting.
ako ng mga 3 membranes,
beses. ability to perspire)
Sinuka ko
yung mga
kinain ko.”