ILOILO DOCTORS’ COLLEGE

COLLEGE OF NURSING
West Avenue, Molo, Iloilo City

NURSING CARE PLAN

Defining Characteristics Nursing Diagnosis Outcome Identification Nursing Interventions Rationale Evaluation
Subjective: Long Term: Independent:
Deficient Fluid Volume related to After 8 hours of  Maintain  To prevent Goals met.
“Sako lang akon pamus on nga active fluid volume loss. nursing adequate further
daw nalupot ako” as verbalized interventions, the hydration, dehydration Long Term:
by the patient. patient fluid volume increase fluid and maintain After 8 hours of nursing
will return to normal. intake. hydration interventions, the
status. patient fluid volume
 Measure  Low urine returned to normal.
intake and out output and
every 4 hours. high specific
Record and gravity
report any indicates
significant hypovolemia.
Objective: Rationale: changes. Short Term:
 (+) Vomiting Volume depletion, or extracellular Include urine After 4 hours of nursing
 (+) Fever fluid (ECF) volume contraction, and stool. intervention patient
 (+) Episodes of LBM occurs as a result of loss of total Short Term:  Provide  To prevent have improved skin
 Awake and weak body sodium. After 4 hours of frequent oral from dryness. turgor and moist oral
 Slightly sunken eye balls nursing intervention care. mucosa.
 Dry oral mucosa patient will have
 Dry skin improved skin turgor Dependent:
 Skin warm to touch and moist oral  Administer IV  To deliver
 Distended abdomen mucosa. fluids as fluids
 Weak lower extremities prescribed. accurately and
Note: Nursing Diagnosis should be at desired
base from (NANDA- Approved rates.
Nursing Diagnosis)  Restrict solid  To allow
food intake, as bowel rest and
indicated. to reduce
intestinal
workload.