NURSING CARE PLAN

Client’s Name: PT. X Date: ______________ Clinical area of assignment: _Medical-Surgical Ward____
Cues/Evidences Nursing Diagnosis Outcome Criteria Nursing Interventions Rationale Evaluation

Subjective: Risk for Deficient Fluid Short-term: Independent: Independent: Short-term:

Volume r/t fever, Within 8 hours of nursing [Link] and monitor vital signs 1. For early detection of fluid Within 8 hours of nursing
“Init akong paminaw interventions, the patient will be interventions, the patient was able
maam, kagahapon pa ni diaphoresis and frequent (BP, pulse, temperature). imbalance and dehydration.
able to: to:
urination 2. Assess for signs of dehydration 2. To identifies early signs of
ug pag mag sige kog  Demonstrate adequate  Demonstrate adequate
hydration status as
(e.g., dry mucous membranes, fluid deficit. hydration status as
inom ug tubig taga taod- capillary refill, decreased skin
taod sad ko mangihi” as evidenced by moist evidenced by moist
mucous membranes turgor, dark/concentrated urine, mucous membranes and
verbalized by the patient and stable vital signs. decreased urine output). stable vital signs.
 Maintain an adequate 3. Encourage increased oral fluid 3. To Help replace fluids lost  Maintain an adequate
oral fluid intake of at intake (2–3L/day), including through fever and diaphoresis oral fluid intake of at
least 2–3L/day (if not electrolyte-rich fluids, if not least 2–3L/day (if not
Objective: contraindicated). contraindicated).
 Elevated body contraindicated.
 Verbalize the  Verbalize the
temperature 4. Monitor intake and output (I&O), 4. Provides information about
importance of importance of
(37.8°C) maintaining proper noting color, character of urine. adequacy of fluid volume and maintaining proper
 Flushed skin, hydration during 5. Provide a cool and comfortable replacement needs. hydration during illness.
warm to touch illness. environment to reduce excessive 5. Prevents further fluid loss and Long-Term Goal:
 Frequent urination Long-Term Goal: sweating. promotes comfort. After 24-48 hours of nursing
 Excessive After 24-48 hours of nursing 6. Ensure proper IVF regulation. 6. To ensure that there is interventions, the patient was able
interventions, the patient will be 7. Educate to avoid food that cause adequate hydration. to:
sweating able to:  Remain free from
dehydration such as coffee and tea 7. To prevent dehydration.
 Remain free from 8. Educate the patient and family 8. Empowers the patient to take complications related to
complications related dehydration (e.g.,
about the importance of hydration, preventive measures.
to dehydration (e.g., hypotension,
hypotension, signs of dehydration, and when to tachycardia, decreased
tachycardia, decreased seek medical attention. urine output).
urine output).
Dependent: Dependent:
1. Administer prescribed 1. To reduce fever and fluid fluid
antipyretics (e.g., acetaminophen) to losses from excessive sweating.
help control fever.