Far Eastern University

Institute of Nursing

Nursing Care Plan

Cues Nursing Rationale Goal and Interventions Rationale Evaluation

Diagnosis Objectives

Deficient Situational Analysis Goal: Goal met.

fluid volume
Observation: related to
-Client appeared
irritable.
excessive
perspiration.
-Client is with fair
reflexes.
-Client has poor skin
turgor assessed at the
abdomen.
-Client has unsunken
eyes and fontanels.
-Client has moist skin
folds including the
antecubital fossa.
-Client has dry mucous
membranes including
the buccal and oral
mucosa.
-Client passed out stool
once in the morning.
Stool was semi-soft,
yellow in color and not
watery.
BP= 120/80 mmHg CR=
90bpm PR= 20cpm
Water content of the After an 8-hour After an 8-
human body progressively shift, client will be hour shift,
fever, decreases from birth to old able to client was
vomiting age. In the neonate, fluid demonstrate able to
and accounts for as much as adequate fluid demonstrate
75% of body weight. Most balance as adequate fluid
of the decrease occurs in evidenced by balance as
the first 10 years of life. good skin turgor, evidenced by
Hypovolemia or extra moist skin and good skin
cellular fluid volume deficit mucous turgor, moist
is the isotonic loss of body membranes; skin and
fluids, that is, relatively caregiver will be mucous
equal losses of sodium able to verbalize membranes;
and water. understanding of caregiver will
child’s fluid needs be able to
Pediatric clients are more and will be able to verbalize
at risk of hypovolemia and demonstrate understanding
dehydration because their behaviors to of child’s fluid
bodies need to have a prevent needs and will
higher proportion of water development of be able to
to total body weight. fluid volume demonstrate
Excessive fluid loss deficit. behaviors to
reduced fluid intake, third- prevent
space fluid shift, and a development
combination of these Objectives: of fluid
factors causes fluid volume
volume loss. Fluid loss deficit.
causes include abdominal Facilitative
surgery, diabetes mellitus, 1.The causative 1.Causative/contributing Objective
1.Note potential sources factors for fluid
diarrhea, vomiting, or precipitating of fluid loss/intake. met.
imbalances.
excessive diuretic therapy, factors that cause
excessive use of laxatives, the client’s 2.Indicators of hydration
excessive perspiration and condition & the 2.Continue monitor the status. Note:
crying, fever, fistulas, degree of fluid vital signs, mucous Hypotension indicative
hemorrhage, nasogastric deficit will be membranes, weight, of developing shock
drainage and renal failure evaluated. skin turgor, breath may not be readily
with polyuria. sounds, urinary and observed in pediatric
gastric output.
Temp: 37.8c.
Fluid shift related to burns
during the initial phase,
vomiting, acute intestinal
obstruction, acute gastro
enteritis, acute peritonitis,
crushing injury, hip or
pelvic fracture (1.5 to 2 L
of blood may accumulate
in tissues around the
fracture), pancreatitis and
pleural effusion may also
contribute to fluid volume
deficit. Another possible
causes of reduced fluid
volume are dysphagia,
coma, environmental
conditions preventing fluid
intake and psychiatric
illness.
Health Implication
Hypovolemia is an isotonic
disorder. Fluid volume
deficit decreases capillary
hydrostatic pressure and
fluid transport. Cells are
deprived of normal
nutrients that serve as
substrates for energy
production, metabolism,
and other cellular
functions. Decreased renal
blood flow triggers the
rennin-angiotensin system
to increase sodium-water
reabsorption. The
cardiovascular system
compensates by
increasing heart rate,
cardiac contractility,
venous constriction, and
systemic vascular
resistance, thus increasing
patients until very late in
the clinical course.
4.Review patient’s 4.Provides baseline and
intake of fluids. Hydrate comparison
with water after every
feeding.
5.Determine child’s 5.Provides information
normal pattern of for baseline and
elimination. comparison.
6. Continue monitor the 6. Consistency with
patient’s weight and weight measurement
compare the result on helps ensure more
the next days. Weigh on accurate results. Weight
the same scale at the is a useful indicator of
same time of day & fluid balance. Weight
wearing same amount loss indicates that child
of clothing is not receiving
adequate fluid
replacement and
adjustments need to be
made.
Supplemental
1.Administer and
monitor IV fluids as 1. Provides fluid & nutritional
support to replace active fluid
ordered.
loss.Close monitoring
and regulation is
required to prevent fluid
overload while
correcting fluid balance.
2.Request for laboratory
2.After 30 results, e.g., 2.Indicators of
minutes of hemoglobin/hematocrit adequacy of
nursing care, the (Hb/Hct), BUN, urine hydration/therapeutic
client will be able osmolality/specific interventions.
to elicit no signs gravity.
of dehydration.
Developmental
1. Instuct the caregiver
to apply moist towel on 1. Moist towel may
client’s lips when noted reduce the dryness of
dry. the oral musosa.
Facilitative
 cardiac output and mean
arterial pressure.
It also triggers the thirst
response, releasing more
antidiuretic hormone and
producing more
aldosterone. When
compensation fails,
hypovolemic shock occurs
in the following sequence:
-decreased intravascular
fluid volume
-diminished venous return,
which reduces preload
and stroke volume
-reduced cardiac output
-decreased mean arterial
pressure
-impaired tissue perfusion
-decreased oxygen and
nutrient delivery to cells,
-multiple organ
dysfunction syndrome
Possible complications of
hypovolemia include
shock and acute renal
failure.
(Lippincott Manual of
Nursing Practice Series
Pathophysiology; 2007;
pp.458-461)
1. Provide fresh water
and oral fluids preferred 1. The oral route is
by the client (distribute preferred for
over 24 hours) provide maintaining fluid
prescribed diet; offer balance Distributing the
snacks. Instruct intake over the entire
significant other to 24-hour period and
assist the client with providing snacks and
feedings as appropriate. preferred beverages Objective
2. After 15 increases the likelihood met.
minutes of that the client will
nursing maintain the prescribed
intervention, client oral intake.
will be able to 2.Auscultate bowel
feed with ease sounds. Note 2.Provides information
and without characteristics of stool about digestion/bowel
undue discomfort. (color, amount, function and may affect
frequency, and so on). choice/timing of
feeding.
Facilitative
1. Provide frequent oral
hygiene, at least twice a 1. Oral hygiene
day decreases unpleasant
tastes in the mouth and
allows the client to
2. Provide comfort respond to the
measures (e.g. clean sensation of thirst.
cloth, clean linens, etc.)
3.Provide a quiet
3. After 15 environment.
minutes of 2. Promotes comfort
nursing level & distraction.
intervention, client Objective
Developmental
will be able to met.
comfortable and 1.Educate caregiver 3.Quiet environment
manifest no signs factors contributing to promotes good rest and
of irritability and dehydration, comfort.
will be able to rest complications of
comfortably. dehydration, signs of
dehydration and 1.Ensures continued
different ways in preventive measures in
preventing dehydration. home setting.
(Pediatric Nursing Care
Plans; Swaeringer;
2006; pp.674-676)
 (Fundamentals of Nursing; Objective
4. After 20 Taylor et. al.; 5th Edition; 2005) met.
minutes of
nursing
action,patient will
be able to
enumerate at
least 3 out 5
infant care
measures of
preventing
dehydration.

Cues Nursing diagnosis Rationale Goals & Objectives Intervention Rationale Evaluation
Subjective: Risk for This infectious After 8 hrs. Of Goal met.
“Isang araw parang Bleeding disease is nursing After 1 hr. Of
dumugo ilong ko related to manifested by interventions, nursing
pero konting konti altered clotting a sudden the client will interventions,
palang naman”as factor. onset of fever, be at reduced risk the client
verbalized by the with severe for bleeding was able to
Patient. headache, demonstrate
muscle and behaviors
Objective: joint pains that reduce
· Weakness and (myalgias and the risk for
irritability. arthralgias— bleeding.
severe pain
· Restlessness. gives it the
name breakbone
· V/S taken as fever or
follows: bonecrusher
BP= 120/80 mmHg disease) and
CR= 90bpm rashes and
PR= 20cpm usually Objectives:
Temp: 37.8c. appears first 1.After 3 hours of Independent: The G.I tract Objective met.
on the lower nursing intervention · Assess for signs (esophagus and
limbs and the the patient will be and symptoms of rectum) is the
chest. There able to identify G.I bleeding. most usual
may also be factors that could Check for source of
gastritis and increase risk of secretions. bleeding of its
some times bleeding. Observe color mucosal
bleeding. and consistency fragility.
of stools or
vomitus. · Sub-acute
 · Observe for disseminated
presence of intravascular
petechiae, coagulation
ecchymosis, (DIC) may
bleeding from one develop
more sites. secondary to
altered clotting
factors.

· Monitor pulse, · An increase in

Blood pressure. pulse with
decreased
Blood pressure
can indicate
loss of
circulating
blood volume.
· Note changes in · Changes may
mentation and indicate
level of cerebral
consciousness. perfusion
secondary to
hypovolemia,
hypoxemia.
2.After 3 hours of · Avoid rectal · Rectal and
Nursing intervention, temperature, be esophageal Objective met
the patient will be gentle with GI vessels are
able to demonstrate tube insertions. most vulnerable
ways to reduce risk to rupture.
for bleeding.
· Encourage use of · In the presence
soft toothbrush, of clotting factor
avoiding straining disturbances,
for stool, and minimal trauma
forceful nose can cause
blowing. mucosal
bleeding.
· Use small
needles for · Minimizes
injections. Apply damage to
pressure to tissues,
venipuncture reducing risk for
sites for longer bleeding and
than usual. hematoma.

· Recommend
 avoidance of · Prolongs
aspirin containing coagulation,
products. potentiating risk
of hemorrhage.
Collaborative:
· Monitor Hb and
Hct and clotting · Indicators of
factors. anemia, active
bleeding, or
impending
complications

Cues Nursing Analysis Goals and Nursing interventions Rationale Evaluation

diagnosis objective
Subjective: Acute Pain Acute pain is an GOAL:
Complaining for (+) pain in related to IV unpleasant sensory and After 2 hours Goal met. The
her IV insertion site and medication/side emotional experience of student client was able
arms.. drip of KCL arising from actual or nurses’ to experienced
potential tissue damage or intervention the gradual
“Ang sakit sakit niya siguro described in terms of such patient’s pain reduction or
dahil sa gamut o kaya damage ; sudden or slow scale will be relief of pain as
baka wala na sa linya ung onset of any intensity from reduced by two evidenced by
IV,” as verbalized by the mild to severe with an while on KCL decreased pain
patient. anticipated or predictable side drip scale from 5/10
end and a duration of less to 2/10, having
A pain scale of 5/10 than six months. Acute OBJECTIVES: Facilitative: normal BP and
pain, which usually occurs After 30 Assess nature and These data provide PR, and
Objective: in response to tissue minutes of degree of discomfort. information about the verbalization of
injury, results from assessment subjective experience reduction of
Grimacing upon touching activation of peripheral with the patient, of discomfort for this pain. The client
of arm pain receptors and their the patient will client. was also able to
specific A delta and C be able to identify 1 cause
Tender to touch and warm. sensory nerve fibers identify at least of pain, and
With slight inflammation. (nociceptors). ways of pain Assess blood pressure Provides baseline choose and
reduction. and pulse and IV site. and comparison apply one way
Pain fibers enter the spinal to alleviate pain.
cord at the dorsal root
BP= 120/80 mmHg CR= ganglia and synapse in the Supplemental and
90bpm PR= 20cpm Temp: dorsal horn. From there, Developmental:
37.8c. fibers cross to the other Assist with measures
side and travel up the that reduce discomfort.
lateral columns to the These include:
thalamus and then to the • Discussion and Reduces discomforts.
cerebral cortex. demonstration
to the client
Repetitive stimulation (eg, breathing
from a prolonged painful relaxation
condition) can sensitize techniques and
neurons in the dorsal horn encouraging
of the spinal cord so that a use of
lesser peripheral stimulus breathing/relax
causes pain (wind-up ation
phenomenon). Peripheral techniques.
nerves and nerves at other
levels of the CNS may • Warm to cold Ice provides local
also be sensitized, compress anesthesia, promotes
producing long-term vasoconstriction, and
synaptic changes in reduces edema
cortical receptive fields formation
(remodeling) that maintain
exaggerated pain
perception. • Reduction of Pain may be
stimulation in associated with
Substances released the anxiety; blood
when tissue is injured, environment pressure and pulse
including those involved in are elevated with
the inflammatory cascade, anxiety.
can sensitize peripheral
nociceptors. These • Provision of Divert pain to other
substances include arm rubs stimulation/sensation.
vasoactive peptides (eg, Provides relaxation.
calcitonin gene-related
protein, substance P, • Teach Forget about the
neurokinin A) and other Diversional feeling of pain by
mediators (eg, activities like focusing on other
prostaglandin E2, sleeping, activities
serotonin, talking with
bradykinin, epinephrine). company,
reading books.

After 2 ½ Facilitative:
hours of Institute comfort Promotes comfort
discussion and measures
demonstration -Warm to cold
to the patient, Compress
the patient will - Slight Arm rubs
be able to apply
at least one
way to alleviate
pain Collaborative Analgesics act on
Administer analgesic as higher brain centers
needed. Assess to reduce perception
effectiveness of pain of pain, promoting
medication. Explain relaxation, facilitating
action of analgesic, rest and sense of
time factors and well-being.
restrictions. Knowledge of typical
After 3 hours of effect aids in
intervention the developing realistic
client will be expectations.
able to Knowledge of time
verbalize restrictions, with
improved reasons, allows client
comfortability. compliance with
orders.