Nursing Care Plan

Diagnosis Need Desired Interventions Rationale Evaluation Intervention Rationale

Outcome Statement Modificatio
n
After 8 hours
• Deficient Fluid
P of nursing
volume r/t fluid losses
H intervention,
through normal routes
Y he will be
as manifested by
S able to:
Hematemesis, blood
I General: • Goal • Cont • To
in stool and an
O Decreased Met. Able to inue prevent
erythrocyte count
L risk of prevent nursing reoccurre
volume equal to 0.11
O complications complicatio intervention nce of the
1. S-“Halos dugo
G of fluid ns of fluid s. disease
na gyud iyang tae,
I volume deficit volume
naga suka na sad
C deficit
siya nga naa dugo”,
Specific: Independent • Goal • To
as verbalized by his 1. To gain

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 wife. N 2. Monitor 1. Establish trust and Met. Able to • Cont prevent

O- Conscious and E Patient’s rapport to cooperation maintain inue reoccurre

coherent E Hydration client and adequate nursing nce of the

- Responds to verbal D Status significant fluid volume intervention disease

stimuli others 2. To obtain s and since

- Body weakness 2. Monitor and baseline data this

noted record vital disease

- Poor skin turgor signs 3. To be needs

- Defecated bloody 3. Assess aware of long term

stool and vomited patient’s patient’s interventi

with presence of condition condition and ons

blood feeling

3. To ensure
V/S: T: 37.8 °C
4. Monitor and accurate
P: 67bpm
record Intake measure of
R: 22cpm
and output fluid status

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 BP: 130/80

mmHg

Health • Goal • To

Background Teachings: 5. To Met. prevent

3. Provide
Knowledge: Deficient 5. Instruct to maintain Actions to reoccurre
Health
Fluid Volume is the increase fluid hydration prevent • Cont nce of the
Teachings
decreased intake status, thus dehydration inue disease
that could
intravascular, preventing and nursing
prevent
interstitial, and/or dehydration occurrence intervention
occurrence of
intracellular fluid. 6. To avoid of the s
complications
This refers to reoccurrence disease.
6. Advise
dehydration with of the
proper hygiene
changes in sodium. disease
to the client
References: 7.To avoid 

Nurses Pocket exhausting

7. Provide
Guide, edition 11 the client, this

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adequate rest may lead

and sleep more on fluid

loss

8.To deliver

Collaborative Fluids

8. Administer accurately at

Intravenous desired rates

Fluid as 9. Reduces

prescribed Nausea and

9. Give prevents

Antiemetics vomiting

medication as

physician’s

order.

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