Integrity • Professionalism • Commitment • Competence • Openness • Teamwork •

Patriotism
Max Y. Suniel St, Cagayan de Oro, 9000 Misamis Oriental
Email: info.coc@phinmaed.com +63 (088) 858-3880 / +63 917-376-5105

Name: _______________________________________________________ RLE Group/Section: _________ Hospital Area: ___________________________

Clinical Instructor: _____________________________________________ Date: __

NURSING CARE PLAN

Priority
No. Subjective Cues
"nag sige ko balik2
2 sa cr sugod ganiha
kadlawon (3am) kay
sakit akong tiyan
hantod sa nagpa
admit nalang jud ko (6am)" as
verbalized by the patient
Sen
Objective Cues Nursing Diagnosis Plan of Care/Objective
Short term:
- weakness Risk for fluid volume deficit related to
- tachycardia active fluid loss as evidenced by diarrhea At the end of 2 hours, the patient will
- dry mucous and vomiting be able to verbalize awareness of
membrane causative factors and behaviors
-abnormal skin essential to correct the fluid deficit and
turgor/non-elastic explain measures that can be taken to
treat or prevent fluid volume loss.
Long term:
At the end of 8 hours, the patient will
be able to have a restored fluid and
electrolyte balance, vital signs will be
within the normal range, maintain an
elastic skin turgor and moist mucous
membranes.
Intervention: Independent
Evaluation
and Dependent
Independent: Short term:
-Encourage the patients to drink clear
fluids frequently in small amounts to
prevent dehydration. Offer oral rehydration
After two hours, the patient will
solutions (ORS), water, clear broth, or
be able to describe behaviours
electrolyte-rich drinks. and causal variables that are
-Maintain good oral hygiene to prevent necessary to address the fluid
discomfort and encourage oral intake. deficit and provide treatment
Provide mouth care to alleviate dry mouth options for either treating or
and promote comfort, which may help preventing fluid volume loss.
increase fluid intake.
-Provide small, frequent meals and snacks
that are easy to digest and gentle on the
Long term:
stomach to prevent further vomiting and
promote nutrient intake. After eight hours, the patient
-Educate the patient and their caregivers should be able to recover their
about the importance of fluid intake, signs fluid and electrolyte balance,
of dehydration, and strategies to prevent have normal vital signs, have
fluid volume deficit. Emphasize the need to moist mucosal membranes, and
replace lost fluids promptly.
have elastic skin turgor.
Dependent:
-Initiate IV fluid therapy as prescribed by
the healthcare provider to rapidly replace
lost fluids and electrolytes in cases of
severe dehydration or when oral
rehydration is insufficient or
contraindicated.
-Administer antiemetic medications as
prescribed by the healthcare provider to
control vomiting and nausea, thereby
reducing fluid loss and improving the
patient's ability to tolerate oral intake.
-Collaborate with other healthcare team
members, such as dietitians, pharmacists,
and specialists, to optimize the patient's
management plan, including dietary
modifications, medication adjustments, and
additional supportive care as needed.
Integrity • Professionalism • Commitment • Competence • Openness • Teamwork •
Patriotism
Max Y. Suniel St, Cagayan de Oro, 9000 Misamis Oriental
Email: info.coc@phinmaed.com +63 (088) 858-3880 / +63 917-376-5105