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FAR EASTERN UNIVERSITY

INSTITUTE OF NURSING

NURSING CARE PLAN

ASSESSMENT ANALYSIS NURSINGPROBLEM

GOALS ANDOBJECTIVES

NURSINGINTERVENTIONS

RATIONALE EVALUATION

Subjective:Themother verbalizes

bigla nalangnanamlay anganak ko at lagisiyang suka ng

suka

Objective: Sunken

eyeballs Dry lips Wet buccal

mucosa. Frequent

loose bowelmovement.

Weak inappearance.

Yellowishwatery

NANDADefinition:

Decreasedintravascular,interstitial,

and/orintracellularfluid. Thisrefers to

dehydration,water loss

alonewithout

change insodium.

Risk fordeficient

fluidvolume r/t

toexcessive

lossesthrough

diarrhea asevidencedby loosebowel

movement.

GOALS: Short-

term:After 8hours ofnursingintervention thepatientwas abletomaintainadequatefluidvolume asevidencedby moist

mucousmembrane, goodskinturgor,andcapillary

reflex.

Determineeffects of

age.

Note clientslevel of

consciousnes

Very youngand

extremelyelderlyindividualsare quicklyaffected byfluidvolumedeficit, andare leastable toexpressneeds.Infants/ youngchildrenand other

nonverbalpersonscannotdescribethirst.

EFFECTIVENESS:

The client will experiencecomfort.

Appropriateness:The SO were able toassist in doing measures

directed towards thereduction of pain

Effectiveness:

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Long-term:

After 2weeks ofnursinginterventions thepatientexperienc

esadequatefluidvolumeandelectrolytebalance asevidenced

by urineoutput,heart rate(HR) 100beats/min,consistenc

y ofweight,andnormalskinturgor.

After 1month of

s ormentation.

Evaluatenutritionalstatus, notingcurrentintake, typeof diet.Noteproblems like

impairedmentation,nausea,fever, facialinjuries,immobilityandinsufficient

time forintake.

Reviewlaboratorydata.

Monitor I/O

balance,being awareof alteredintake oroutput.

Weight client& comparewith recent

Toevaluate

ability toexpressneeds.

It cannegatively

affect fluidintake.

The client will no longerexperience pain.

Acceptability:The patients SO wereable to verbalizewillingness to cooperatewith the health care

provider in promotingpatients wellness

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nursinginterventi

on themother ofthe clientwilldemonstratebehaviour

s orlifestylechangesto preventdevelopment offluidvolume

deficit.

OBJECTIVES: After 10

mins. ofdiscussionthe

mother ofthe childwill beawareabout therisk factorof fluidvolume

weighthistory.Perfor

m serialweights.

Assess skinturgor/ oralmucousmembranes.

Monitor VitalSigns likeorthostatichypotensiontachychardiaand fever.

To obtainbaselinedata.

To assureaccurate

picture offluidstatus.

Todetermine

trends.

Inadequate

indicatorsofadequacyof fluidvolume,althoughoralmucous

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deficit. After 10

mins. ofdiscussionthemother ofthepatientcan name

3 out of 5possiblecauses offluidvolumedeficit.

After 10mins. of

discussionthemotherwill knowthedefinitionof fluid

volumedeficit.

After 10mins. Ofnursingintervention thepatients

membranes and

maybe drybecause ofmouthbreathingandsupplemental

oxygen.Presence ofthesesymptomsreducesoral.

Elevated

temperature orprolongedfeverincreasesmetabolicrate and

fluid lossthroughevaporation.Orthostatic BPchangesandincreasing

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motherwill know

thereason fortherequiredintake andthespecific

amountneeded. After 10

mins. Ofnursingintervention thepatients

mothercanidentify 3out of 5complications offluid

volumedeficit.

tachychardia may

indicatesystemicfluiddeficit.

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