Nursing Care Plan Form
Student Name:
Patient Identifier:
Nursing Diagnosis (use PES/PE format):
Assessment Data
(Include at least three-five
subjective and/or objective
pieces of data that lead to the
nursing diagnosis)
Insufficient fluid volume
associated with nausea,
vomiting, and diarrhea,
manifested by decreased
urine output, increased
urine concentration, fever,
weakness, decreased
skin/tongue swelling, dry
mucous membranes,
increased HR, and
decreased BP
Date:
Patient Medical Diagnosis:
Goals & Outcome
(Two statements are required
for each nursing diagnosis.
Must be Patient and/or family
focused; measurable; time-
specific; and reasonable.)
The patient will maintain
serum sodium, potassium,
calcium, phosphorus,
magnesium and / or pH
within the normal range
The patient must have a
normal blood volume, a
urine output greater than
30 ml/hour, and a normal
Nursing Interventions
(List at least three nursing or
collaborative interventions with
rationale for each goal &
outcome.)
Obtain samples according
to instructions to test for
abnormal potassium levels
(for example, potassium
in serum and urine).
Potassium supplement
(PO, NG or IV) according
to policy management
regulations.
Monitor the neurologic and
neuromuscular
manifestations of
hypokalemia (eg, muscle
weakness, lethargy,
changes in level of
consciousness).
1. Monitor the cardiac
manifestations of
Rationale Outcome Evaluation &
(Provide reason why Replanning
intervention is (Was goal met? How would
indicated/therapeutic; provide you revise the plan of care
references.) according to the patient’s
response to current plan ?)
Urine and serum tests can Patient lab result are
provide information on within normal limit
extracellular potassium
levels. There is no practical
way to measure
intracellular K
2. Low Potassium Levels
Dangerous, Patient May
Need Supplements.
3. Potassium is an
important electrolyte for
bone and smooth muscle Outcome #2
activity
1. Many heart rhythm
disorders can be caused
 skin elasticity
The customer will maintain
the fluid volume at a
Deficient Fluid Volume functional level through
r/t Active fluid loss- stable vital signs, good skin
filling, good capillary
burns, manifested by
filling, moist mucous
Tachycardia, membranes and sufficient
Tachypnea, Weak urine of normal specific
gravity.
pulses.
hypokalemia (hypotension,
tachycardia, weak pulse,
irregular rhythm).
2. Monitor cardiac
manifestations of
hypernatremia (eg,
orthostatic hypotension and
tachycardia).
3. Monitor the nervous
system and neuromuscular
manifestations of
hypernatremia (for
example, lethargy,
seizures, hyperreflexia, and
irritability).
Monitor CVP and vital
signs. Pay attention to
elevated body temperature
and orthostatic
hypotension.
by hypokalemia.
Monitoring heart function
during hypokalemia is
essential.
2. The heart responds to
fluid loss by increasing its
heart rate to compensate
for the increase in cardiac
output. Low fluid volume
can cause blood pressure
to drop.
3. Due to the low volume
of body fluids,
hypernatremia creates
hypertonic vascular
spaces, causing water to
move from cells, including
brain cells. This is the
cause of neurological
symptoms.
Tachycardia is associated
with varying degrees of
hypotension, depending on
the degree of fluid
deficiency. CVP
measurement helps
determine the degree of
fluid deficiency and
response to alternative
therapies. Fever increases
metabolism and

The client will demonstrate
appropriate monitoring
and correction of defects.
Investigate reports of
sudden or severe chest
pain, cyanosis, irritability,
increased anxiety, and
difficulty breathing.
Monitor lab studies, as
ordered.
Assess the client's ability
to manage their own
moisture.
Monitor urine output.
Measure or estimate fluid
loss from all sources, such
as sweating, wound
drainage, and gastric loss.
exacerbates fluid loss
Increased blood levels
and platelet aggregation
can cause a systemic
embolism.
Depending on the degree of
fluid loss, there may be
different electrolyte and
metabolic imbalances that
need to be corrected.
Factors that affect
customers’ ability to
replenish fluids through
the mouth include
impaired swallowing and
nausea reflexes, anorexia,
oral discomfort, nausea,
and changes in mentality.
Liquid replacement needs
are based on correcting
current deficiencies and
ongoing losses. Decreased
urine output may indicate
insufficient blood volume,
insufficient renal perfusion,
or possible polyuria,
requiring more aggressive
fluid replacement.
 Determine the customer's
beverage preferences and Relieves thirst and dry
develop a 24-hour fluid mucosa discomfort and
intake program. Encourage increases parenteral
foods high in liquid replacement.
content.

Deficient Fluid Volume

r/t acute renal failure,
manifested by
Confusion,
restlessness, Dark
concentrated urine,
Decreased urine
volume.