NURSING CARE PLAN: FLUID VOLUME DEFICIT

Name of Patient: Crispy Chicken

Age: 49 years old
Chief Complaint: Loose Bowel Movement (LBM) and vomiting
Diagnosis: Acute Appendicitis

ANALYSIS/
NURSING GOAL AND NURSING
CUES HEALTH RATIONALE EVALUATION
DIAGNOSIS OBJECTIVES INTERVENTIONS
IMPLICATION

INTERACTION: Fluid Volume IMMEDIATE GOAL

According to the Deficit related to CAUSE After 8 hours of EFFECTIVENESS
client: active fluid Active fluid nursing 1. Was the client able to
“Tatlo o apat o volume loss (e.g volume loss (e.g
intervention, the be evaluated in the
kaya minsan diarrhea) diarrhea) client will be able to degree of fluid deficit?
limang beses ako maintain fluid __yes __no why?
dumudumi INTERMEDIATE volume at a
simula kaninang CAUSE functional level 2. Was the client’s
7am (November Decreases condition able to be
8, 2006), matubig mucosal OBJECTIVES corrected/ replaced
siya hindi siya absorption losses to reverse
buo” (1) Evaluate a. Assess vital signs Provides baseline pathophysiologic
“Dalawang beses ROOT CAUSE degree of fluid for assessing and mechanism?
lang ako umiihi Bacterial deficit evaluating __yes __no why?
simula kaninang infection interventions.
7am (November (Smeltzer & Bare, 3. Was the client able to
8, 2006) HEALTH Medical Surgical do the measures
“Nanghihina ako” IMPLICATION Nursing, 10th ed., designed provided to
“May kinain lang Complications of pp.245) allow the GI tract to
ako, di ko na diarrhea include rest?
matandaan kung the potential for b. Note physical Predictors of fluid __yes __no why?
ano un, tapos cardiac signs of dehydration balance that should
makalipas ng dysrythmias be in client’s usual (4) Was the client able
ilang oras because of range in a healthy to return to a regular
nahihilo na ako significant fluid state. (Nurse’s diet?
tapos medyo and electrolyte Pocket Guide, 9th __yes __no why?
nilalagnat tapos loss. (Smeltzer edition by
nagususka tapos & Bare, Medical Doenges, et al EFFICIENCY
nanghihina” Surgical page 240) Was the interventions
 ANALYSIS/
NURSING GOAL AND NURSING
CUES HEALTH RATIONALE EVALUATION
DIAGNOSIS OBJECTIVES INTERVENTIONS
IMPLICATION
Nursing, 10th (2) Correct/replace a. Administer To limit done within the time
According to ed., pp. 1032) losses to reverse medications gastric/intestinal frame?
client’s son Complications of pathophysiologic (antiemetics or losses; to treat __yes __no why?
“Nagsusuka siya regional enteritis mechanism antidiarrheals or bacteria (Nurse’s
tapos maputla. include intestinal antibiotics) Pocket Guide, 9th APPROPRIATENESS
Minsan sinasabi obstruction or edition by Were the interventions
niya na masakit stricture Doenges, et al pp. suitable to the client?
ang kanyang formation, 248) __yes __no why?
tiyan.” perianal
disease, fluid b. Encouraged fluid To detect early ACCESSIBILITY
OBSERVATION and electrolyte intake and signs of Were the interventions
Pale in color imbalance, monitoring of daily dehydration acceptable to the
Appeared weak malnutrition from fluid intake and (Smeltzer & Bare, client?
malabsorptiuon, output Medical Surgical __yes __no why?
MEASUREMENT and fistula and Nursing, 10th ed.,
3x loose stool abscess pp 1014) ADEQUACY
Decreased urine formation. Were the interventions
output (2x since Smeltzer & (3) Provide a Administer nothing Allowing the gastric adequate to meet the
7am) Bare, Medical measures by mouth—possibly mucosa to heal client’s needs?
Surgical designed to allow for days—until acute (Smeltzer & Bare, __yes __no why?
Laboratory Nursing, 10th the GI tract to rest symptoms subside Medical Surgical
Results: ed., pp.1042) Nursing, 10th ed.,
Sodium: 129 b. Maintain bed rest pp. 1012)
mmol/L (132-
142mmol/L) (4) Promote return a. Offer the client Fluid electrolyte
WBC: 15.19/L to a regular diet ice chips followed replacement
(4.5-11.0x109/L) by clear liquids provides oral
replacement
therapy (Medical-
Surgical Nursing,
4th edition by
Lippincott pp. 204)