JOHN PAUL RICHARD MINDANAO

BS NURSING NURSING CARE PLAN FOR FLUID IMBALANCE

TIME/SHIFT ASSESSMENT DIAGNOSIS PLANNING IMPLEMETATION RATIONALE EVALUATION

6-2 “Nakakailang dumi na Fluid volume deficit  The patient will  Assess and record  To assess any  After 8 hours of
8 am ako ngayong araw, related to excessive report less vital signs. underlying nursing
pakiramdam ko defecation defecation and symptoms. To intervention, the
nadehydrate na ako” maintains document goal is met as
as verbalized by the adequate fluid assessment. evidenced by stool
patient. intake within 8  IV fluids regulated  To hydrate patient frequency
hours of nursing at 40gtts/min. with adequate decreased into 2x
T- 36.8 intervention.  Advise patient to fluid per day. The
P-98 increase fluid  To avoid patient also
R- 20 intake. excessive maintains
BP- 130/90  Assess abdominal dehydration adequate fluid
02sat- 98% pain, its location,  To assess the intake.
frequency and pain, its location,
>abdominal pain duration. duration and
P-unpredictable  Educate patient to frequency.
Q-stabbing pain avoid fatty or
R-epigastic region greasy food  Greasy food may
S-8/10 result to worsen
T-sudden  Monitor patient’s abdominal pain.
>sunken eyeballs intake and output.
>poor skin turgor  To assess the
>dry mucosa patient’s
>pallor
 Advised patient to condition if
>frequent defecation hydrated or not.
have adequate rest
(5x a day)
and sleep.
>hyperactive bowel
 Adequate rest
sound
 Encourage patient and sleep will
to eat small, promote comfort.
frequent meals and
to consume foods  Small frequent
food avoids
constipation.
 NURSING CARE PLAN FOR ELECTROLYTE IMBALANCE

TIME/SHIFT ASSESSMENT DIAGNOSIS PLANNING IMPLEMETATION RATIONALE EVALUATION

6-2 “Parang madalas Excess fluid volume  The patient will  Assess and record  To assess any  After 8 hours of
8 am akong mag crave sa may be related to report less intake vital signs. underlying nursing
maaalat ngayon” as excessive sodium of sodium and symptoms. To intervention, the
verbalized by the intake. decrease in blood document goal is met as
patient. pressure hours of assessment. evidenced by
nursing  IV fluids regulated  To hydrate patient decreased in blood
T- 36.8 intervention. at 40gtts/min. with adequate pressure and
P-103  Advise patient to fluid decrease in
R- 20 increase fluid  To avoid sodium intake.
BP- 140/90 intake. excessive
02sat- 98%  Assess abdominal dehydration
pain, its location,  To assess the
frequency and pain, its location,
>Bounding pulses duration. duration and
>Distended neck and  Educate patient to frequency.
peripheral vein avoid fatty or
>Edema grade 2 greasy food  Greasy food may
>dry mucosa result lipid
>pallor  Monitor patient’s accumulation in
>shortness of breath intake and output. blood vessels.
>dry mucus membrane
>decreased in urinary  To assess the
output (600cc/day)
 Advised patient to patient’s
have adequate rest condition if
and sleep. hydrated or not.

 Encourage patient  Adequate rest

to eat small, and sleep will
frequent meals and promote comfort.
to consume foods
that normally  Small frequent
cause constipation food avoids
and are easy to constipation.
 digest

 Give  To normalized
antihypersentive blood pressure
medication to within normal level
patient with
physicians
prescription

 Educate patient  To educate client

about the in decreasing
importance of sodium intake
avoiding sodium

 Advised patient in  Low salt- low fat

his current diet diet is needed to
(low fat- low salt aggreviating of
diet the signs and
symptoms of
excessive sodium
intake.