URDANETA CITY UNIVERSITY

San Vicente West, Urdaneta City, Pangasinan 2428

COLLEGE OF HEALTH SCIENCES

Bachelor of Science in Nursing

NURSING CARE PLAN (NCP)

Name of Student: Alipio, Rosemarie T. Year Level and Group: BSN-III

Affiliating Agency/Area: Month/Year of Exposure:

Assessment Nursing Diagnosis Planning Intervention Rationale Evaluation

(at least 10)

Subjective: Problem, Etiology, Signs Short Term Goal: Independent: short Term Goal Evaluation
(P.E.S.) format S.M.A.R.T. + Evidence
“I’m having lbm  Assess vital signs  Provides baseline for After 8 hrs. of nursing
8x a day and Fluid Volume Deficit After 8 hrs of nursing assessing and intervention, the patient is able to
vomiting 4x a day intervention, evaluating maintain fluid volume at a
related to active fluid
for the past two interventions functional level
days after eating volume loss (e.g patient will be able to
raw tuna from a diarrhea) maintain fluid volume at a  Note physical signs of  Predictors of fluid
Japanese functional level dehydration GOALS MET
balance that should
restaurant” as
be in client’s usual
verbalized by the
patient range in a healthy
Objective: INFERENCE Long Term Goal: state. Long term Goal Evaluation
(at least 5) Scientific Explanation S.M.A.R.T.+ Evidence
(Diagram Form) After 3 days of nursing
 sunken After 3 days of nursing  Assess the volume and  Vomiting is associated intervention the patient is able to
Intestinal fluid output intervention, the patient frequency of vomiting. with fluid loss. maintain adequate fluid volume
eyelids overwhelms the will maintain adequate as evidence by moist mucous
 very absorptive capacity of fluid volume as evidence  Assess the client’s skin  A loss of interstitial fluid membranes, good skin turgor,
the GI tract by moist mucous turgor and mucous causes the loss of skin and capillary refill.
dry membranes for signs of
membranes, good skin turgor. Assessment of the
skin dehydration. skin turgor in adults is GOAL MET
turgor, and capillary refill.
 Lack of less accurate since their
skin normally loses its
energy damage to the villous
elasticity. Therefore the
delaye brush border of the
skin turgor assessed over
intestine
d skin the sternum in the
forehead is best. Several
turgor.
longitudinal furrows and
Vital Signs taken as coating may be noted
follows: malabsorption of along the tongue.
BP: 90/60 intestinal contents
CR: 115  Educative  Increased fluid intake
RR: 25  Encourage increase replaces fluid lost in the
Temp: 37.8. fluid intake of 1.5 to liquid stool. Being
2.5 liters/24 hour creative in selecting fluid
plus 200 ml for each sources (e.g., flavored
leading to an osmotic loose stool in adults gelatin, frozen juice bars,
diarrhea unless sports drink) can facilitate
contraindicated. fluid replacement. Oral
hydrating solutions (e.g.,
Rehydrate) can be
considered as needed.
release of toxins that
bind to specific  Fluid deficit can cause a
enterocyte receptors  Encourage regular dry, sticky mouth.
oral hygiene. Attention to mouth care
promotes interest in
drinking and reduces the
discomfort of dry mucous
membranes.
Fluid Volume Deficit
related to active fluid  The client with
volume loss (e.g.  Instruct the client to gastroenteritis may
diarrhea) monitor weight daily experience weight loss
and consistently with from fluid loss with
the same scale,
diarrhea and vomiting.
preferably at the
Instruction facilitates
same time of the
day, and wearing the accurate measurement
same amount of and assessment provides
clothing. useful data for
comparisons and helps in
following trends.

 Enough knowledge aids

 Educate patient the patient to take part in
about possible cause his or her plan of care
and effect of fluid
losses or decreased
fluid intake.

Dependent:  These drugs will reduce

 Administer vomiting and the risk for
antiemetic fluid volume deficit.
medications as
ordered
 Fluids are necessary to
 Administer parenteral maintain hydration
fluids as prescribed. status. Determination of
 Consider the need for the type and amount of
an IV fluid challenge fluid to be replaced and
with immediate infusion rates will vary
infusion of fluids for depending on clinical
patients with status.
abnormal vital signs.

Interdependent/Collaborative
 A central venous line
 Assist the physician with allows fluids to be infused
insertion of central centrally and for
venous line and arterial monitoring of CVP and
line, as indicated. fluid status. An arterial
line allows for the
continuous monitoring of
BP.

Checked by: _________________________________ Date: ____________________

Clinical Instructor’s Name and Signature