Nursing Care Plan 1

Assessment Nursing Diagnosis Planning Nursing Intervention Rationale Evaluation

Dehydration -After 8 hours of After 8 hrs of
S: andami niya na related to nursing Independent: nursing
pong isinuka, hindi ko vomiting as intervention, Monitor and document vital Decrease in circulating blood intervention
na po mabilang as manifested by clients vomiting signs especially BP and volume can the patient
verbalized by the poor skin turgor will stop and HR. cause hypotension and displayed
mother. and dry mucous reduced tachycardia. Alteration in HR is improvement
O: membranes. a compensatory mechanism to on the
dry mucous -After nursing maintain cardiac output. Objective cues
membranes intervention, a Usually, the pulse is weak and
poor skin slight decrease in may be irregular if electrolyte
turgor skin turgor will be imbalance also occurs.
observed.
Vital Signs: Assess Urine Color, Urine A normal urine output is
BP: 90/60mmHg Intake and Output every 4 considered normal not less than
HR: 120 hours. 30ml/hour and Gconcentrated
beats/minute urine means fluid deficit.
I&O:
4/18: 1,050
4/19: 1,200
Assess skin turgor and oral Signs of dehydration are also
mucous membranes for detected through skin.
signs of dehydration.

Assess color and amount of These factors influence the

urine. intake and output or any other
fluid needs.
 Note the presence of
nausea and vomiting, and
fever.
Dependent:
Encourage to increase fluid
intake.
Collaborative:
Give/supervise administ
ration of IV fluids.
To decrease the risk of
dehydrations complication and
hypovolemia.
An accurate measure of fluid
intake and output is an
important indicator of patients
fluid status.
To decrease the risk of
dehydrations complication and
hypovolemia.