Nursing Care Plan – Formulate a Plan (QSEN: PCC/TC/IN/STY/EBP) (CLO: 1, 3, 4, 5, 6,

7, 8, 10, 11, 12, 13)

Complete 2 of these every week
ASSESSMENT NURSING GOAL/OUTCOMES ACTION RATIONALE EVALUATION
DIAGNOSIS
Subjective / A client need or What changes you What actions are Why you did Did the plan work?
Objective Data problem related expect/desire needed and what you did. How do you know?
to what system is related to the when. Some Reason from What changes are
affected as identified actions may textbook for needed to make
evidenced by problem. include an order planned actions. the plan work?
(AEB). from healthcare Include book and
provider. page number.
Subjective DX The client will: Actions to support Specific to your Evaluate each
Patient states that Risk for fluid and Demonstrate stable outcomes client Outcome
he is retired and is electrolyte fluid and electrolyte Specific to your Patient net intake and
physically active at imbalance balance client: Urine output can be output was +32mL.
home 1. Monitor input an indicator for Goal met.
and output and hypovolemia or
R/T
Patient states that As Measured by: calculate total onset of renal Patient’s levels of
Active fluid loss
he does not damage (Ackley pg. sodium, potassium,

m
secondary to fluid balance
routinely take 371) magnesium, calcium,

er as
Ogilvie syndrome 1. Net intake and
medications at and chloride were
output within +/-

co
home. He does within normal range.
300 mL 2. Monitor

eH w
occasionally when Increases and Goal met.
his blood pressure AEB sodium, decreases in
is high Having liquid bowel potassium, electrolytes are Patient’s skin turgor

o.
movements every 2. Electrolytes are indicators of fluid returned to normal
magnesium,
Patient states that 30 minutes
rs e within normal chloride, and volume imbalances within 1 second. Goal
ou urc
his bottom is ranges (Ackley pg. 376) met.
Reports of nausea calcium labs.
feeling raw
and vomiting Notify health
Patient reports care provider if
vomiting before NPO and 3. Skin turgor that under normal
o

arriving at the nasogastric tube in returns to normal range and supply

aC s

hospital place in 3 seconds or any supplements These are

less symptoms of
vi y re

Objective decreased body

3. Assess skin
Patient is fluids (Ackley pg.
turgor, color, and
experiencing 5 out 380)
temperature
of 10 pain in the
abdomen
ed d

Clients need to be
QSEN Teach:
ar stu

Patient has been aware of the signs

having liquid bowel 4. Teach family and symptoms in
movements every and patient order to know
30 minutes about when to contact
their health care
complications of
is

Patient has provider Ackley pg.

deficient fluid 378)
abdomen
and electrolytes
Th

distention, nausea,
and a decreased
appetite
QSEN Discharge: Clients must know
Patient is NPO 5. Importance of proper fluid intake
in order to maintain
sh

and has a maintaining a

proper fluid a balanced state
nasogastric tube (Ackley pg. 374)
in place intake

This study source was downloaded by 100000807824865 from CourseHero.com on 05-30-2021 11:46:16 GMT -05:00

https://www.coursehero.com/file/31007848/Risk-for-Fluid-and-Electrolyte-imbalances-Nursing-Care-Plandocx/
Powered by TCPDF (www.tcpdf.org)