Nursing Care Plan

ASSESSMENT NURSING PLANNING IMPLEMENTATION RATIONALE EVALUATION

DIAGNOSIS
Subjective: Risk for Imbalanced STG: At the end of 1 Dependent: Isotonic solution At the end of 8 hours
none Fluid Volume R/T hour of nursing Regulate IVF (D5LR) rehydrates cells to nursing interventions, is
Objective: Intravascular to interventions, will to desired rate replace fluid loss due now asleep on bed; V/S
 Pale and weak Extravascular Plasma gradually abate signs to increased vascular normal
in appearance; Leakage Secondary and symptoms of permeability.
 Petechial rashes to Increased fluid volume
on upper Vascular deficiency as Vol./Vol. To maintain
extremities Permeability. evidenced by normal Replacement; equivalent intake and
V/S and an monitor I/O output rate,
Definition: The state improving skin color. preventing
at which an dehydration
individual is at risk of LTG: At the end of 2 Independent:
experiencing days nursing Give health To assist in
vascular, cellular, or interventions, will teachings to replacement and
intracellular maintain fluid increase fluid prevention of fluid
dehydration due to volume at an intake. loss and to provide
water retention in amount optimum for external means of
hemorrhaging. normal functioning oral rehydration.
as evidenced by
regular urine output,
stable vital signs, Instruct how to ORESOL effectively
moist mucus properly create replaces fluid and
membranes and ORESOL and electrolyte loss and is
skin, good capillary instruct to take budget-friendly.
refill time. once a day.