NURSING CARE PLAN

Name of Patient:____________________________________________________________________________Age:_____________Civil Status:____________________Religion:_____________________________________________________________

Address:______________________________________________________________________________________Informant:_________________________________Relationship:______________________________________________________________
Chief Complaint:____________________________________________________________________________Medical Diagnosis: DYSTOCIA

IMPLEMENTATION

ASSESSMENT Rationale/Justifications
PROBLEM LIST PLANNING
(cues & evidences/ (Nursing Theories of Care,
DATE (according to NURSING DIAGNOSIS (objectives-long term EVALUATION
objective &
priority) & short term) Nursing Developmental stage,
subjective) References
Interventions tasks, Principles, EBP,
Standards of Nursing
Practice)
04/2/202 Loss of fluid  Assessment Risk for deficient  Plan of care  Monitor I&O  To ensure accurate Edition 12  Identify
0 through abnormal findings, fluid volume and who is balance, being picture of fluid Nurse’s individual
routes (e.g. noting involved in aware of altered  To determine pocket guide risk factors
Indwelling tubes) existing planning intake or output trends and
conditions  Teaching  Weigh client  For any changes Diagnoses, appropriate
contributin plan and compare  Note for changes prioritized interventions
g to and with recent (e.g. orthostatic interventions  Demonstrate
degree of weight history hypotension, , and behaviors or
fluid  Assess skin tachycardia, rationales lifestyle
retention turgor and oral fever) changes to
(vital signs, mucous Pg. 379-382 prevent
amount, membranes development
presence,  Monitor vital By: of fluid
and signs for Marilynn E. volume
location of changes Doenges deficit
edema; and
weight Mary Frances
changes) Moorhouse
 I&O Fluid
balance Alice C. Murr
 Results of
laboratory
test and
diagnostic
studies

Name of Student Nurse and Signature: Ang, Aila Queen C.,SNBC Year and Section:_BSN-2 Date/Duration of Patient Care:_April 2,2020
Name of Clinical Instructor: Felice Mae Pelicano-Ju, RN,MN________________________________________Rating:________________________Remarks:________________________________________________________