NURSING CARE PLAN

Cues Nursing Diagnosis Rationale to Goals and Objectives Nursing Interventions Rationale to Nursing Evaluation
Nursing Diagnosis Interventions
Subjective cues:  Risk for Deficient fluid Short term range Independent: Short term:
“I cannot tolerate deficient fluid Volume is decrease After 8 hours of nursing After 8 hours of
fluids because of volume d intravascular, intervention, the patient 1. Monitor intake and 1. Provides nursing interventions
nausea and vomiting, related to interstitial, and/or will maintain adequate output, character and information the client;
and I has liquid inadequate intracellular fluid. fluid volume as evidence amount of stock about overall  Understand the
stools 2-4 times per fluid intake as This refers to by good skin turgor and estimate insensible fluid balance, importance of
day.” as verbalized by the evidence by dehydration, water balance intake and fluid losses. Measure renal function, maintaining
patience. poor skin loss alone without output: urine specific gravity and bowel water in our
turgor. change in sodium. 1. After 10 mins. of and observe for disease control, body.
nursing oliguria. as well as
Source: Nurses intervention, the 2. Assess vital signs guidelines for  Patient
Objective Cues: client will 3. Observe for fluid increased her
Pocket Guide p.90
Physical Marillon E. verbalize excessively dry skin replacement. fluid intake.
understanding of and mucous 2. Hypotension
Examination Doerges, MAEY
Frances drinking water in membranes, (including
o Moorhouse, alice maintaining our decreases skin postural),
T: 38.6 C (101.5 body. turgor, slowed tachycardia,
o C, Murr
F) 2. After 15 mins of capillary refill fever can
nursing 4. Weigh daily indicate
intervention the 5. Maintain response to or
Pulse: 96 beats/min client will restrictions, bed rest effect of fluid
increase her fluid and avoidance of loss
intake. exertion. 3. Indicates
excessive fluid
BP: 102/84 mmHg loss or resultant
of dehydration
4. Indicator of
Diagnostic Data overall fluid
and nutritional
Urine specific
 Long term range: status. Long term range:
gravity: 1.035 After 1-2 days of 5. Colon placed at After 1-2 days of
Serum sodium: 145 nursing intervention the rest for healing nursing intervention
mEq/L client will be able to: and to decrease the patient:
intestinal fluid  Demonstrated
Serum potassium:  Patient losses. lifestyle
3.5 mEq/L demonstrate changes to
avoid
Chest x-ray: s lifestyle
progression of
negative changes to dehydration
avoid Dependent:  Patient
progression Dependent: 1. Fluids are verbalized
Scant urine output of 1. Administer necessary to
awareness
 Dry oral dehydration. parenteral fluids as maintain
prescribed. Consider hydration of causative
mucosa, the need for an IV status. factors and
 Patient
 furrowed verbalizes fluid challenge with Determination behaviors
tongue, immediate infusion of the type and essential to
awareness
of fluids for patients amount of fluid
 cracked lips of causative correct fluid
with abnormal vital to be replaced
factors and signs. and infusion deficit.
behaviors 2. Administer blood rates will vary  Patient
essential to products as depending on
clinical status. explained
correct fluid prescribed.
2. Blood measures
deficit. that can be
transfusions
 Patient may be taken to
explains required to treat or
measures correct fluid prevent fluid
loss from volume loss.
that can be
active
taken to  Patient
gastrointestin
treat or described
al bleeding.
 prevent fluid Collaborative: symptoms
volume loss. 1. Assist the 1. A central that indicate
physician venous line the need to
 Patient with allows fluids
consult with
describes insertion of to be infused
health care
symptoms central centrally and
provider.
that indicate venous line for monitoring
the need to and arterial of CVP and
consult with line, as fluid status.
indicated. An arterial line
health care
2. Provide allows for the
provider.
measures to continuous
prevent monitoring of
excessive BP.
electrolyte 2. Fluid losses
loss (e.g., from diarrhea
resting the GI should be
tract, concomitantly
administering treated with
antipyretics antidiarrheal
as ordered by medications, as
the prescribed.
physician). Antipyretics
can decrease
fever and fluid
losses from
diaphoresis.