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Nursing Care Plan

CUES Nursing Analysis Goals and Nursing Rationale Evaluation


Problem Objectives Intervention
Cues: Deficient fluid Immediate
volume related to cause: Within 8 hours, Goal met.
Subjective: prolonged Prolonged patient will Independent: > Increased HR Patient
-according diarrhea diarrhea maintain Monitored vital along maintained
to her adequate fluid signs; with decreased adequate
daughter, -Decreased Intermediate volume noted changes BP and fluid volume as
her mother intravascular, cause: as evidenced in body elevated evidenced by
experiences interstitial, and/or by: temperature. temperature, normal vital
diarrhea for intracellular fluid. is present in signs,
5 days This refers to > vital signs conditions with adequate
-“natakot dehydration, within normal fluid urinary output
talaga kami water loss alone Root cause: range for age volume deficit. with
nung ang without change Multiple Increased body normal specific
tagal ng in sodium. disease > urine output temperature also gravity, moist
nagtatae ni of 50- increases fluid mucous
nanay kaya 80ml/hr loss by membranes,
dinala na increasing good skin
namin siya > urine specific metabolism. turgor, and
sa ospital” gravity patient’s
-“hindi na between 1.004 Observed for > Patients with verbalization
masyadong and postural may that
makakilos 1.030 BP changes; experience thirst is not
si nanay encouraged varying excessive.
kasi mahina > moist gradual degrees of
na siya, mucous position postural
kaya kami membranes changes. hypotension
na lang nag > good skin depending
aalaga sa turgor on degree of fluid
kanya”, as volume deficit.
verbalized > patient
by her verbalizing
daughter that thirst is no Palpated > Excessive fluid
longer peripheral loss
Objective: excessive pulses, through
-the client’s assessed regulatory
skin is dry capillary refill, mechanisms
-the client mucous failure
experiences membranes, may result in
oliguria and skin severe
-client’s turgor; dehydration,
BMI is 16.2 observed for cuirculatory
-client has changes in collapse,
decreased mental and shock.
skin turgor status. Decreased
cerebral
perfusion may
result in changes
in
mentation.

Monitored I/O > Fluid


qh; replacement
obtained daily needs are based
weights on
and compared correction of
with 24- current
hr I/O. deficits and
ongoing
losses.
Decreased
urinary output
may
require
aggressive
fluid
replacement. A
sudden weight
increase may
indicate
third-spacing.

Encouraged > Relieves thirst


increase in and
fluid intake and aids in body fluid
consumption of replacement.
foods
high in fluid
content.

Turned patient > Patients with


q2h fluid
and provided volume deficit
support are
for body more at risk for
prominences. skin
breakdown.
Provided skin > Regular skin
and and
mouth care, mouth care
massaged relieves
skin, and dryness and
applied discomfort. Light
emolients as massage
necessary. promotes
circulation. Use
of
emolients and
mild
soaps promotes
good
hygiene and
comfort
without
excessive
drying of the
skin.

Monitored IV > Patients on IV


flow fluid
rates regularly; therapy may be
observed for at
marked risk for
elevations in cardiopulmonary
BP, compromise.
restlessness,
moist
cough,
dyspnea,
basilar
crackles, and
frothy sputum.

Provided health > Lifelong fluid


teachings on replacement to
the need control polyuria
for lifelong and
hormonal polydipsia is
replacement. necessary
for patients with
Diabetes
Insipidus.

Dependent:

Administered > Aggressive


IV fluids fluid
as ordered. replacement may
be
required to
correct
fluid volume
deficit.
Administered
desmopressin > Desmopressin
(DDAVP) is the
intanasally as drug of choice for
ordered. Diabetes
Insipidus.

Collaborative:

Monitored > Other


laboratory imbalances
studies such as that require
urine correction
specific gravity, may be present
electrolytes, with
and fluid volume
blood deficit.
coagulation
studies