NURSING CARE PLAN

ASSESSMENT DIAGNOSIS PLANNING INTERVENTIONS RATIONALE EVALUATION

Objective: Deficit fluid volume At the end of the Weight px regularly Changes in weight
- Sudden weight loss r/t fluid loss to shift, no signs of provide
subcutaneous tissue dehydration will be information in fluid
- Decreased urine noted imbalance and the
output adequacy of fluid
volume
- (+) dry skin replacement

- (+) dry mucous Monitor intake and 1.040 indicates

membranes output. Note urine severe
color, and measure hypovolemia and
- Muscle weakness specific gravity as kidney
indicated involvement. Note:
Administration of
MgSO4 may cause
transient increase
increase in output

Monitor Blood These changes of

pressure and Pulse v/s are associated
Rate with fluid volume
loss and/or
hypovelemia

Check on dietary Proper nutrition

intake of proteins decreases
and calories incidence of
prenatal
hypovolemia and
hypoperfusion.
Intake of 80100 g
NURSING CARE PLAN

of protein may be
required daily to
replace losses.

Place px on strict This enhances

regimen of bedrest; placental and renal
encourage lateral perfusion, reduces
position adrenal activity,
and may lower BP

Increase fluid intake Fluid replacement

as needed treats
hypovolemia, yet
must be given
cautiously to
prevent overload

Encourage to avoid To prevent further

food that cause dehydration
dehydration such as
coffee and tea

Monitor serum uric Elevated levels,

acid and creatinine especially of uric
levels, and BUN acid, indicate
impaired kidney
function,
worsening of
maternal condition,
and poor fetal
outcome

Administer platelets Patients with HELLP

as indicated syndrome awaiting
NURSING CARE PLAN

delivery of the
fetus may benefit
from transfusion of
platelets when
count is below
20,000

Watched out for Observe further

further signs of signs of
dehydration dehydration that
may also lead to
hypovolemia