DAVAO DOCTORS COLLEGE

General Malvar St., Davao City

Nursing Program

NURSING CARE PLAN

Name of Patient: Patient. D. Z. Date of Admission: January 15, 2023 Room: 401a
Age: 42 years old Sex: Female Civil Status: Married Chief Complaint: irregular contraction coupled with lower back pain
Religion: N/A Attending Physician: Dr. Ran

GOALS/OBJECTIVES NURSING
PROBLEM SCIENTIFIC BASIS RATIONALE EVALUATION
CRITERIA INTERVENTIONS
DATE: January 15, 2023 Nursing Diagnosis: After 8 hours of nursing INDEPENDENT: January 15, 2023
Risk for Deficient Fluid care, the patient will be 1. Assess and monitor 1. Vital signs may also 4:00PM
TIME: 8:00 AM Volume related to High able to: the client’s vital signs. give ideas as to the “GOAL PARTIALLY MET”
glucose levels in the blood hydration status of the After 8 hours of nursing
Subjective Data: and urine as evidenced by patient and must be care, the patient:
 Patient stated “Nag- Urine dipstick and OGTT monitored.
anha ko unta karon
results
diri kay para  demonstrate 2. Assess the client’s 2. These are good  Demonstrates
magpa-prenatal adequate hydration peripheral pulses, indicators of hydration lifestyle changes to
Scientific Basis:
lang, pero nalipong as evidenced by capillary refill, skin and adequacy of avoid progression of
Also referred to as Fluid
man ko atong stable vital signs. turgor, and mucous circulating volume. dehydration.
Volume Deficit (FVD),
paingon ko diri uy membranes.
hypovolemia, and even
mao naka-desisyon
dehydration, is a state in
ko magpa-admit  establish a normal 3. Monitor the client’s 3. Measuring the client’s  Was able to
which the fluid volume
nalang. Nagkaon urine output with the intake and output; intake and output maintain glucose in
homeostasis is disturbed
man ko bag-o ko absence of glucose. note urine-specific provides an ongoing a satisfactory range
due to various factors such
nigawas sa balay gravity. estimate of volume by taking the
as blood loss or body fluid
para magpa-check- replacement needs, prescribed
and electrolyte loss.
up. Dili hinuon kayo  demonstrate normal kidney function, and medication but still
daghan ako nakaon, blood glucose levels. effectiveness of the needs to give
mga half bowl of REFERENCES: therapy. further teaching on
cereals ug isa ka Curran. Rn, A. B. (2022, May maintaining proper
baso na orange 18). Fluid Volume Deficit. 4. Assess for changes in 4. Changes in mentation nutrition.
juice lang. Wala ko NurseStudy.Net. mentation and level of can be due to
kabalo ngano https://nursestudy.net/fluid consciousness. abnormally high or
nalipong jud ko. “ -volume-deficit-nursing- low glucose,
Objective Data: diagnosis/ electrolyte
● (+) Hypothermia abnormalities,
● (+) Tachycardia decreased cerebral
● (+) OGTT perfusion, acidosis, or
 1 hour: 190 mg/dL developing hypoxia.
 2 hours: 165 mg/dL
● Pale, Tired, and Sleepy 5. Promote a 5. Cover the client with
● Doesn’t drink much comfortable light sheets to avoid
water environment. overheating,
● 3+ glycosuria promoting further
fluid loss.
Vital Signs:
Weight: 170 lbs 6. Encourage increased 6. Diabetic pregnant
BP: 130/80 mmHg fluid intake unless women may need
PR: 99 bpm contraindicated. more fluid intake due
RR: 23 cpm to physiological
T: 35.8 oC changes in the mother
and fetal growth.
DEPENDENT:
7. Administer 7. Intravenous solutions
intravenous fluids, as replace intravascular
ordered. and extravascular
fluids and replenish
electrolyte losses.
They also dilute both
the levels of glucose
and circulating
counterregulatory
hormones.

8. Administer potassium 8. Potassium should be

and other electrolytes added to the IV as
intravenously or by soon as the urinary
oral route, as flow is adequate to
indicated. prevent hypokalemia.
The amount and
timing of potassium
replacement depend
on the serum
 potassium
concentration.
COLLABORATIVE:
9. Monitor laboratory 9. to evaluate the body’s
studies, such as response to fluid loss
hematocrit, BUN, and to determine
creatinine, serum replacement needs.
osmolality, sodium,
and potassium.

10. Discuss 10. This promotes timely

signs/symptoms intervention.
indicating need for
emergent or further
evaluation and follow-
up.

Michelle Facto
BBN/DTS/2020 NAME OF STUDENT