Nursing Care Plan

Patient’s Name: Age: Sex: Address:

Pathophysiologic/
Assessment Desired Nursing
Nursing Diagnosis Schematic Rationale Evaluation
Cues Outcome Intervention
Diagram
Subjective Risk for deficient fluid After 8 Independent After 8 hours
Cues: volume r/t excessive Predisposing hours of Interventions: of
Patient losses through frequent Factors: Nursing Nursing
verbalized, diarrhea. Contaminated Intervention  Monitor intake  Provides Intervention,
“Naga sakit food or water, , the and output, information the
akon tiyan kag Recent travel to patient and character, and about over all patient and
ka lima ko ma Definition: places, Raw food, significant amount of fluid balance, significant
mus-on. Ka State or condition Seafood other stools; renal function, other
duwa ko mag where the fluid output will be able estimate and bowel was able to:
suka.” exceeds Precipitating to: insensible disease control,
the fluid intake. Factors: Ingestion fluid losses. as well as Maintain
Objective of contaminated Maintain Measure urine guidelines for adequate
Cues: Source: food or water. adequate specific fluid fluid volume
 Restlessnes https://www.rnpedia.com/ fluid gravity and replacement. as evidenced
s nursing- Trophozoite volume as observe for by good skin
 Irritability notes/communicable colonization evidenced oliguria.  Hypotension(including turgor and
 Facial -diseases- by good postural), tachycardia, balance
grimace notes/amoebiasis/ Multiplication on skin turgor  Assess vital fever can indicate intake and
 Dry skin mucosa and balance signs(BP, response to or effect of output.
 V/S taken Vomiting intake and pulse, fluid loss.
 as follows: Diarrhea output. temperature).  Indicates
Loss of appetite excessive fluid
T: 37 C P: Weight loss  Observe for loss or resultant
79bpm R: Decreased Na excessively of dehydration.
19bpm BP: Decreased K dry skin and
110/70mmhg mucous
membranes,
Nursing decreased skin
Diagnosis turgor, slowed
capillary refill.  Indicator of
Risk for deficient overall fluid and
fluid volume r/t  Weigh daily. nutritional status.
excessive losses
through frequent Dependent
diarrhea. Interventions:  To increase Na &
K levels
 Administering  To replace fluids
medication lost by vomiting
 Changing of and diarrhea
IV fluid bag
 Collection and analysis
of patient data to
 Fluid regulate fluid balance
monitoring
Nursing Care Plan
Patient’s Name: Age: Sex: Address:
Pathophysiologic/
Desired Nursing
Assessment Cues Nursing Diagnosis Schematic Rationale Evaluation
Outcome Intervention
Diagram
Subjective Cues: Fatigue r/t disease After 8 hours Independent After 8 hours of
“Ga pamuloypoy process and poor Predisposing of Interventions: Nursing
akon lawas, physical condition Factors: Nursing Intervention, the
matyag ko daw ka Nutrient Intervention,  Assess the  Fatigue may patient and
luya gid sa akon” Definition: deficiency the patient’s be a symptom significant other
as verbalized by An overwhelming patient and nutritional of protein- was able to:
the patient. sustained sense of significant ingestion for calorie
exhaustion and other adequate energy malnutrition,  Patient
Objective Cues: decreased capacity Precipitating will be able to: sources and vitamin verbalized
 Decreased for physical and Factors: metabolic deficiencies, or feelings of
performance mental work at usual Active  Verbalize demands. iron increased
 Jittery level. inflammation increased  Observe deficiencies. energy and
behavior energy and physiological  Tolerance improved well
 Irritability Source: improved reaction to varies being.
 V/S taken as https://nurseslabs.co Psychological well being activities such significantly,  Patient
follows: m comorbidities and as any depending on demonstrates a
T: 38 C /fatigue/ sleep disturbance alterations in the phase of more positive
P: 70bpm.  Identify BP, respiratory the disease and happier
R: 19bpm Persistent fatigue potential rate, or heart progression, attitude than
BP:120/80 factors that rate. nutrition before the
aggravate condition, interventions
and relate fluid balance, were applied
fatigue and quantity or  Patient is able
Nursing sort of to record
Diagnosis opportunistic aggravating
diseases that factors that led
Fatigue r/t disease patient has to determining
process and poor been subjected relieving
physical condition to. factors.

Dependent
Interventions:  To
 Administering increase
medication Na & K
levels