NURSING CARE PLAN

Client: S.C. Age: 22

Medical Diagnosis: Deficient fluid volume Gender: Female

PRIORITY #1: Deficient fluid volume related to fluid loss secondary to diarrhea

ASSESSMENT PLANNING INTERVENTION RATIONALE EVALUATION

Subjective Short-term goal Independent After doing the necessary
>Client reports dryness of >Assess for the signs of >To determine the cause nursing interventions and
her oral mucosa At the end of this shift, the dehydration including skin of pharyngeal pain. This teachings, the client:
client exhibit signs of turgor, oral mucosa, etc. will provide a data that
Objective improvement in hydration could be used to evaluate >Achieved appropriate
>Vital signs status. the proper intervention urine output
T:35.4 that the client needs.
PR:60
RR:22 >Review ways to improve >Encourage the client to >To reduce the dryness of >Participated in health
BP:100/60 the client’s hydration increase the fluid intake. the oral mucosa teaching
>pale conjunctiva status

>normal appetite >Monitor I & O and IV >To determine if IV fluid

>Ensure that the client is fluids and electrolyte >Followed the prescribed
>has intermittent fever receiving right amount of replacement are needed pharmacological regimen.
maintenance fluids.
>decreased skin turgor >Keep a quiet >To reduce stress and
environment and calm anxiety >Demonstrated use of
>normal capillary refill >Provide comfort activities. relaxation skills to reduce
time measures anxiety
>Provide health teachings >To promote awareness on
>elevated WBC count on avoidance of related factors
dehydration
 •
PRIORITY #2: Deficient knowledge (Learning need) regarding electrolyte imbalance as evidenced by verbalization of
questions and concerns.
ASSESSMENT PLANNING INTERVENTION RATIONALE EVALUATION
Subjective: Short term goal:
>Assess level of >Some clients may need >Client responded to the
>Verbalization of >Assist client to use given knowledge of the client. the help of SO or learning plan and actions
questions: information in all caregivers to learn. performed.
“Ano bang causes ng applicable areas including
dehydration at environmental causes >Determine the client’s >Client might not be
gastroenteritis?” readiness and barriers to physically or emotionally >Client provided a
>Provide information and learning. capable at this time. positive feedback and
self-learning modules adherence to the teaching.
Objective: regarding her disease >Identify support persons. >Reinforcement learning
>Vital signs (e.g. mother, other family process allows the client to
T:35.4 members) proceed at her own pace. >Client was able to deal
PR:60 >Give information with her anxiety.
RR:22 accurately and clearly.
BP:100/60 >Teach the client to cease >To give awareness on the
alcohol consumption possible complications of
>Inaccurate understanding because of the possible having vices
of her disease’ complications.
(pathophysiology)

>Begin with the info the >Can arouse interest/limit

client already know and sense of being
move to what she does not overwhelmed.
know, progressing from
simple to complex.
 PRIORITY #3: Imbalanced Nutrition: Less than body requirements related to inadequate intake and fluid loss
secondary to vomiting and diarrhea
ASSESSMENT PLANNING INTERVENTION RATIONALE EVALUATION

Subjective: Short term goal: Independent: After 8 hours of nursing

care/teaching, patient has:
“Ang laki ng pinayat ko.” >Assess risk/presence of >Familial traits or cultural
conditions associated with >Obtain commitment for beliefs may place high
>Decrease food intake rapid weight loss achieving desirable importance on food intake
weight. as well as large body size. >Verbalize adherence to
>Reported presence of (e.g. wrestler, football the plan of teaching for
nausea in the morning >Encourage client to adhere to lineman, Samoan) attaining the desirable
her prescribed diet (55:20:25) body weight with an
>Sedentary lifestyle is optimal maintenance of
Objective: frequently associated with health.
>Vital signs >Provide information obesity and is a primary
T:35.4 regarding her specific focus for modification.
PR:60 nutritional needs. >Inform the client the
RR:22 proper amount and kind >To help the client to >Client verbalizes her
BP:100/60 of food that she needs to have a control on her goals by changing her
eat, including: high eating habits. eating patterns, food
>decrease 5% of the carbohydrates; low fat quantity/quality, and
weight and protein; liquids with joining in an exercise
high electrolyte content, programs/
>Poor skin turgor and solid to semi-solid
foods.
>Pale conjunctiva