Nursing Care Plan – DEFICIENT FLUID VOLUME

ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION

PT: RC After 8 hours of nursing Independent:

Date: 9-9-2010 Risk for deficient interventions, the • Monitor intake and output • Provides information about After 8 hours of
fluid volume related patient will maintain (I&O). Note number, overall fluid balance, renal nursing
SUBJECTIVE: to diarrhea. adequate fluid volume character, and amount of function, and bowel disease interventions, the
as evidenced by moist stools. Estimate control, as well as patient was able to
“madalas ako mucous membranes, insensible fluid losses guidelines for fluid maintain adequate
dumumi” verbalized good skin turgor, and like diaphoresis. Measure replacement. fluid volume as
by patient. capillary refill. urine specific gravity and evidenced by moist
observe for oliguria. mucous
Objective: • Assess vital signs. Blood • Hypotension, tachycardia, membranes, good
pressure, pulse and fever can indicate response skin turgor, and
• Facial mask of temperature. to and or effect of fluid loss. capillary refill.
pain. • Indicates excessive fluid
loss or resultant
• Frequent watery dehydration.
stools. • Observe for excessively
dry skin and mucous
• V/S taken as membranes, decreased
follows: skin turgor, slowed
capillary refill. • Indicator of overall fluid and
nutritional status.
T: 37.7 • Weigh daily. • Colon is placed at rest for
PR:88 healing and to decrease
R: 20 intestinal fluid losses.
Bp: 110/80 • Inadequate diet and
• Maintain oral restrictions, decreased absorption may
bedrest and avoid lead to vitamin K deficiency
exertion. and defect in coagulation,
potentiating risk for
hemorrhage.
• Observe for overt • Excessive intestinal loss
bleeding and test stool may lead to electrolyte
daily for occult blood. imbalance.

• Maintenance of bowel rest

• Note generalized muscle
weakness or cardiac
dysrhythmias.
requires alternative fluid
replacement to correct loses
or anemia.
• Determines replacement
needs and effectiveness of
Nursing Care Plan – DEFICIENT FLUID VOLUME

therapy.

Collaborative:
• Administer parenteral
fluids, blood transfusions
as indicated.

• Monitor laboratory
studies.