Nursing Care Plan Pedia

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Republic of the Philippines

UNIVERSITY OF NORTHERN PHILIPPINES

College of Nursing

Tamag, Vigan City, 2700 Ilocos Sur

NURSING CARE PLAN

In Partial Fulfillment

Of the Requirement In The Course:

Related Learning Experience CL

Submitted by:

John Noeh D. Degracia


BSN III-E

Submitted to:

Ms. Jermie Allen Alconis, RN


Clinical Instructor
Republic of the Philippines
UNIVERSITY OF NORTHERN PHILIPPINES
College of Nursing
Tamag, Vigan City, Ilocos Sur

ASSESSMENT NURSING SCIENTIFIC PLANNING NURSING RATIONALE EVALUATION


DIAGNOSIS BACKGROUND INTERVENTION
SUBJECTIVE: Deficient IMMEDIATE Short Term: Independent: After performing
Fluid Volume CAUSE: all the nursing
“Isarwa na met sir nu related to After 8 hours Monitor vital signs Helps identify when intervention, the
pakanek, adda met a bassit nausea, Active fluid volume of nursing a patient has an goal is met since
makan na ngem nakapoy ti vomiting, and loss intervention, elevated heart rate or the patient
appetite na nga mangan ken diarrhea as the patient blood pressure, maintained fluid
mariknak ket agkapsot suna INTERMEDIATE was able to which could indicate
evidenced by CAUSE:
volume at
lalo ket tallo nga aldawen decreased demonstrate dehydration functional level,
nga on and off ti gurigor na. urine output, adequate well hydrated,
Decrease Mucusal
Nakabisbissag pay dagita skin/tongue hydration as intake is equal as
mata ken nabasa takki na”, turgor, dry evidenced by Dehydration can be output, and
ROOT CAUSE:
as verbalized by the S/O of mucous adequate prevented by normal skin turgor
Promote increase
the patient” membranes Bacterial Infection intake of increasing the and mucous
in fluid intake and
water. patient's fluid intake membranes
OBJECTIVE: encourage to eat
Long Term: foods with high by two glasses of
 Nausea/vomiting HEALTH
fluid content fluid per day,
 Poor Skin Turgor IMPLICATION: After 2-3 which can lead to
 Poor appetite Complications of days of fewer falls, less
diarrhea and
 Weak in appearance nursing frequent urinary
vomiting include the intervention, infections and
 Sunken Eyeball potential for cardiac
 Dry skin and the patient laxative
dysrhythmias
mucous membranes show urinary prescriptions.
because of
output
 Decreased urine significant fluid and Very useful
output electrolyte loss.
within Assess color and
normal information to help
 Diarrhea amount of urine diagnose
ranges,
Republic of the Philippines
UNIVERSITY OF NORTHERN PHILIPPINES
College of Nursing
Tamag, Vigan City, Ilocos Sur

hydrated dehydration and its


DEFICIENT FLUID skin and concentration.
VOLUME mouth.

Skin turgor and


Assess skin turgor mucous membrane
and mucous moisture provide
membranes valuable indicators
of hydration status.

Dehydration can
Monitor fluid I/O lead to electrolyte
abnormalities, it is
important the nurse
monitors the I/O to
determine the status
of fluids in the body
requirements.

DEPENDENT: To help body


recover and faster
Start oral and IVF rehydration.
rehydration
therapy as
indicated
Republic of the Philippines
UNIVERSITY OF NORTHERN PHILIPPINES
College of Nursing
Tamag, Vigan City, Ilocos Sur

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