Nursing Diagnosis: Fluid volume deficit R/T increased urine output and decreased fluid intake as evidence by 250
– 400 ml urine output twice
per 2hrs.
DEFINING CHARACTERISTICS
Subjective data:”6 glasses of
water ako mahurot each day, and
if ma ngihi ko 250 – 400ml ako
ma ihi.” as verbalized by the
patient.
Objective data:
 Increased urine
output
 Decreased fluid intake
 Concentrated colored
urine
 Dry skin noted
 Dry lips noted
Vital signs:
 BP: 110/80
 Temp: 36.5°c
 PR: 90bpm
 RR: 18cpm
SCIENTIFIC BASIS EXPECTED OUTCOME
Deficient Fluid Volume (also Short Term:
known as Fluid Volume Deficit  Within 1 hour of
adequate health
(FVD), hypovolemia) is a state or
teaching the patient
condition where the fluid output
will be able to
exceeds the fluid intake. It occurs
verbalize ways to
when the body loses both water avoid dehydration.
and electrolytes from the ECF in  Within 1 hour of
similar proportions. Common adequate health
sources of fluid loss are the teaching the patient
will able to verbalize
gastrointestinal tract, polyuria,
importance of
and increased perspiration. Risk
healthy life style.
factors for deficient fluid volume  Within 1 hour of
are as follows: vomiting, health teaching,
diarrhea, GI suctioning, sweating, patient will be able
decreased intake, nausea, to explain measures
inability to gain access to fluids, that can be taken to
treat or prevent fluid
adrenal insufficiency, osmotic
volume loss.
diuresis, hemorrhage, coma,
third-space fluid shifts, burns,
Long term:
ascites, and liver dysfunction.
Fluid volume deficit may be an  After 3 days,
patient will
acute or chronic condition
report
managed in the hospital, improvement of
outpatient center, or home fluid intake and
setting. fluid output.
NURSING INTERVENTION RATIONALE
 Encourage to  This will allow the
drink bountiful patient to trace her
daily activity, just like
amounts of fluid
what is needed to be
as tolerated or
done within that day.
based on patient
needs.
 Encourage  In this way we can help
patient to eat increase the fluid
foods that are intake of the patient.
high in fluid
content.
 Instruct the  This will help prevent
dehydration.
patient to avoid
foods that can
cause
dehydration (tea,
coffee, and soft
drinks)
 Proper monitoring
 Assess patients’ helps us determine the
fluid intake and improvement of the
patient’s condition
output.
 Wayne, G. B. (2021, October 3).
Deficient Fluid Volume
(Dehydration) Nursing Care Plan.
Nurseslabs.
https://nurseslabs.com/deficient-
fluid-volume/

REFERENCES: NANDA
 Nursing Diagnosis: Imbalanced nutrition: more than body requirement r/t physical changes as evidence by patients BMI 26.2 indicates
overweight.

DEFINING CHARACTERISTICS SCIENTIFIC BASIS EXPECTED OUTCOME NURSING INTERVENTION RATIONALE

Imbalanced nutrition Short Term:  Establish guidelines  This will allow the patient
Subjective data:”After nako ma becomes "more than body  Within 1 hour of and goals of activity to trace her daily activity,
nganak mas kusog ko mo kaon.” as adequate health just like what is needed
verbalized by the patient. requirements" when the with the patient
teaching the patient to be done within that
intake of nutrients
will be able to day.
exceeds the metabolic verbalize
needs. It takes root when understanding of  Set appropriate short-  Improvement in
Objective data:
a person food intake is importance of healthy term and long-term nutritional status may
 Height: 4’8ft
more than what the body life style. take a long time. Patient
 Weight: 53kg goals.
uses to generate  Within 1 hour of may lose interest in the
 Weight is 10% over ideal
adequate health whole process without
for height and frame. energy,hence need for
teaching the patient short-term goals.
 BMI: 26.2 imbalanced nutrition care
will able to
 Triceps skinfold: 26mm plan to control the understand and  Advise patient to  Measuring food alerts
 Waist circumference problem.If the condition verbalize ways to patient to normal portion
89cm measure food
persists, it can cause improve body weight. regularly. sizes. Estimating amounts
 Striae is noted can be extremely
obesity, sleep disorders,
 acanthosis nigricans inaccurate.
noted type 2 Diabetes mellitus,
Long term:
Vital signs: infertility in women, and After 7 days, the patient
 Encourage water  Water helps in the
 BP: 110/80 aggravated will be able to report
intake. elimination of byproducts
 Temp: 36.5°c musculoskeletal problems. decrease in weight. of fat breakdown and
 PR: 90bpm It also shortens life helps prevent ketosis.
 RR: 18cpm expectancy
 Success rates are higher
Nursing Writing Services.  Include family, when the family
(2012). Imbalanced caregiver, or food incorporates a healthy
Nutrition: More than Body preparer in the eating plan.
Requirements Care Plan.
 nutrition counseling.

REFERENCES: NANDA
Nursing Diagnosis: Disturbed sleep pattern r/t inadequate sleep hygiene as evidence by patients verbal report 5hr of sleep.

DEFINING SCIENTIFIC EXPECTED NURSING RATIONALE

CHARACTERISTICS BASIS OUTCOME INTERVENTION
Subjective: “5hrs or less ra Disturbed sleep pattern is the Short-term:  Established  To promote
gyud ako tulog taga time limited interruptions of  Within 20 minutes rapport to the cooperative of
adlaw” as verbalized by sleep amount and quality due to of adequate health patient. the patient.
the patient external factors. Alteration in teaching the
sleep pattern; difficulty in daily patient will be able  Obtaining
 Obtain a sleep
functioning; difficulty initiating to verbalize plan patient sleep
sleep; dissatisfaction with sleep; to implement history history allows as
feeling unrested; unintentional sleep promotion to have base line
Objective: awakening. routines. data.
 Dark circles  Within 1 hour
underneath the  Keep
(Betty J. Ackley, Gail B. Ladwig, patient will be able  Noise led to
eyes are noted Mary Beth Flynn Makic : Nursing environment more
to fall asleep
 Drowsiness is Diagnosis Handbook Eleventh without difficulty. quiet during fragmented
noted Edition)  Within 1 hour sleep periods. sleep, less slow-
 Patient appears patient will be able wave (deep)
lethargic to remain asleep sleep, more
 Patient frequent throughout the arousals, and
yawning night and be more time awake
 Slope appearance, awaken naturally, when played
posture feeling refreshed during sleep
and is not fatigued
during day.
Long-term:  Showed
 Within 7 days of  Offer earplugs perception of
nursing when feasible. sleep in critical
interventions the care improved
patient will be able with initial
 Dim the lights
to maintain a earplug use.
during client
regular schedule
sleep periods.  the number of
of sleep and awakenings
waking. decreased when
monitored
lighting levels
were part of a
multicomponent
program to
decrease sleep
disruption
 Offer eye covers
when lighting
cannot be  Clients who were
dimmed. Be offered eye covers
reported that eye
aware that use of covers were
eye covers in helpful for
intubated clients improving sleep.
may lead to
sensory
deprivation and
anxiety.
 Consolidate
 Deepest stages
essential care to
of sleep occurred
provide during the first 3
opportunity for to 4 hours of the
uninterrupted sleep period
sleep the first 3 followed by
to 4 hours of the several 90- to
110-minute
sleep period.
sleep cycles that
Follow with consisted of
periods of 90 to increasingly
110 minutes lighter
 between percentages of
interruptions. sleep
 If client must be
 High frequency
disturbed the
of nocturnal care
first 3 to 4 hours interactions left
of the sleep clients with no
period, attempt 90-minute blocks
to protect 90- to of uninterrupted
110-minute time for sleep.
Protocols for
blocks of time
consolidating
between
care, the number
awakenings. of client nights
that contained a
3-hour window
of interrupted
sleep was
increased.

 Assess for  To assist quality

medications and sleep of patient
other stimulants
that fragment
sleep. Use
caution when
administering
sleep
medications.  Having full meals
 Educate the just before
patient on the bedtime may
produce
proper food and
gastrointestinal
 fluid intake such upset and hinder
as avoiding heavy sleep onset.
meals, alcohol, Coffee, tea,
chocolate, and
caffeine, or
colas which
smoking before contain caffeine
bedtime. stimulate the
nervous system.
This may
interfere with
the patient’s
ability to relax
and fall asleep.
Alcohol produces
drowsiness and
may facilitate the
onset of sleep
but interferes
with REM sleep.

 L-tryptophan is a
component of
 Encourage milk which
patient to take promotes sleep.
milk.  This will refrain
the patient from
 Remind the
going to the
patient to avoid bathroom in
taking a large between sleep.
amount of fluids  These activities
before bedtime. provide
 Introduce relaxation and
relaxing activities distraction to
prepare mind
such as warm
 bath, calm music, and body for
reading a book, sleep.
and relaxation
exercises before  Providing a
bedtime. designated time
 Prevent the for these
patient from concerns allows
thinking about the patient to
next day’s “let go” of these
problems at
activities or any
bedtime.
distracting
thoughts at
bedtime.  These kinds of
 Render bedtime activities
facilitate
nursing care such
relaxation and
as back rub and promote the
other relaxation onset of sleep.
techniques.
Nursing Diagnosis: Activity intolerance related to sedentary life style as manifested by patient verbal report of less activity
DEFINING
CHARACTERISTICS
Subjective: “Dili na gyud
kay ko ka lihok lihok or
maka exercise kay busy
na gyud” as verbalized
by the patient
Objective data:
•Heavy breathing is
noted
•Slow pace movement is
noted
•Pain in lower
extremities noted
SCIENTIFIC EXPECTED
BASIS OUTCOME
Activity Tolerance is defined Short-term:
as Insufficient physiological or  With in 1 hour of  Established rapport
psychological energy to adequate health
endure or complete required teaching the
or desired daily activities. patient will be  Have the patient
able to verbalize
Risk for activity intolerance understanding on
vulnerable to insufficient energy
physiological or psychological conservation
technique.
energy to endure or complete
required or desired
 With in 1 hour of
daily activities, which may
adequate health
compromise health
teaching the
(Betty J. Ackley, Gail B. patient will able 
to understand and
Ladwig, Mary Beth Flynn
verbalize home
Makic : Nursing Diagnosis
remedies, just
Handbook Eleventh Edition) like foods to eat
to improve
generalized
weakness.
Long-term:
 After 1 to 2 days
of nursing
intervention, the  Dangle the legs
patient will be
NURSING RATIONALE
INTERVENTION
To promote
to the patient. cooperative of the
patient.
Helps in increasing the
perform the activity tolerance for the
more slowly, in a activity.
longer time with
more rest or
pauses, or with
assistance if
necessary.
Gradual progression of
Gradually increase the activity prevents
activity with active
overexertion.
range-of-motion
exercises in bed,
increasing to sitting
and then standing.
Prevents orthostatic
hypotension.
from the bed side
 able to report for 10 to 15
increases in minutes. Activities should be
exercise planned ahead to
 Instruct patient to
gradually coincide with the
plan activities for
 After 1 to 2 days patient’s peak energy
times when they
patients report’s level. If the goal is too
decrease in have the most
low, negotiate.
physiological energy.
signs of Duration and
intolerance
 Gradually progress frequency should be
patient activity with increased before
the following: intensity. Exercise
Range-of-motion maintains muscle
(ROM) exercises in strength, joint ROM,
bed, gradually and exercise tolerance.
increasing duration Physical inactive
and frequency patients need to
(then intensity) to improve functional
sitting and then capacity through
standing. repetitive exercises
Deep-breathing over a long period of
exercises three or time. Strength training
more times daily. is valuable in
Sitting up in a chair enhancing endurance
30 minutes three of many ADLs.
times daily.
Walking in room 1
to 2 minutes TID.
Walking down the
hall 20 feet or
walking through
 the house, then
slowly progressing
walking outside the
house, saving
energy for the Patient may be fearful
return trip. of overexertion and
potential damage to
the heart. Appropriate
 Provide emotional
supervision during
support and early efforts can
positive attitude enhance confidence.
regarding abilities.

Knowledge promotes
awareness to prevent
the complication of
overexertion.
 Teach the patient
and/or SO to
recognize signs of
physical over
activity or
overexertion.
These techniques
reduce oxygen
consumption, allowing
a more prolonged
activity.
 Teach energy
conservation
techniques, such
as:

Sitting to do tasks

Frequent position
changes

Pushing rather than

pulling

Sliding rather than

lifting

Working at an even
pace

Placing frequently
used items within
easy reach

Resting for at least

1 hour after meals
before starting a
new activity

Using wheeled
carts for laundry,
shopping, and
cleaning needs
Organizing a work-
rest-work schedule
 Nursing Diagnosis: Disturbed body image r/t changes in physical appearance

DEFINING SCIENTIFIC BASIS EXPECTED OUTCOME NURSING RATIONALE

CHARACTERISTICS INTERVENTION

Situational low self-esteem refers to having a Short Term: •Help client to •Identification is early
Subjective data:”After negative perception of self, owing to situation  Within 1 hour of nursing identify stage of problem
nako ma nganak mas education, the patient will
kusog ko mo kaon.” as changes such as loss of body parts or be able to understand that environmental solving process.
verbalized by the patient. functional abilities. Low self-esteem is often a this are normal changes in factors which
result of real or anticipated lifestyle changes, pregnancy increase risk
fear, negative feelings, relationship issues, low for low self-
 Within 1 hour of adequate
Objective data: resilience, or rejection by others. Stretch health teaching the patient esteem.
 Striae noted in marks are narrow, streak-like lines that can will able to express her
anxieties.
the abdomen, develop on the surface of the skin. They •Encourage •Allowing the client to
axilla, and usually appear on your tummy, or sometimes Long term: client to clarify thoughts and
buttocks. on your upper thighs and breasts, as your  After 2 to 3 days of verbalize feelings promotes
 acanthosis pregnancy progresses and your bump starts to nursing intervention, the thoughts and self-acceptance
nigricans patient will be able to
grow. verbalize acceptance to
feelings about
noted
changes in her body. the current
NHS. (n.d.). Stretch marks in pregnancy. NHS situation.
choices. Retrieved September 29, 2021,
from •To help the patient
•Don’t give
https://www.nhs.uk/pregnancy/related- to be more determine
false hope to
conditions/common-symptoms/stretch-
marks/. the client
•This will help the
•Encourage client to regain her
self esteem.
the use of
cream to
lighten the
striae.
REFERENCES: NANDA