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    1ST NCP

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    Gerrico Trumata
    The document outlines a nursing assessment, diagnosis, plan of care and interventions for a patient presenting with weakness, fever, decreased urine output and inability to tolerate oral fluids due to nausea, vomiting and diarrhea, resulting in a diagnosis of fluid volume deficit. The plan is to monitor the patient's intake and output, increase IV fluids, monitor for signs of dehydration and hypernatremia, and normalize lab results through correction of the fluid deficit over 8 hours of nursing intervention.

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    1ST NCP

    Uploaded by

    Gerrico Trumata
    176 views2 pages
    The document outlines a nursing assessment, diagnosis, plan of care and interventions for a patient presenting with weakness, fever, decreased urine output and inability to tolerate oral fluids due to nausea, vomiting and diarrhea, resulting in a diagnosis of fluid volume deficit. The plan is to monitor the patient's intake and output, increase IV fluids, monitor for signs of dehydration and hypernatremia, and normalize lab results through correction of the fluid deficit over 8 hours of nursing intervention.

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    Ncp

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    1ST-NCP

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    The document outlines a nursing assessment, diagnosis, plan of care and interventions for a patient presenting with weakness, fever, decreased urine output and inability to tolerate oral fluids due to nausea, vomiting and diarrhea, resulting in a diagnosis of fluid volume deficit. The plan is to monitor the patient's intake and output, increase IV fluids, monitor for signs of dehydration and hypernatremia, and normalize lab results through correction of the fluid deficit over 8 hours of nursing intervention.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Download as docx, pdf, or txt
    176 views2 pages

    1ST NCP

    Uploaded by

    Gerrico Trumata
    The document outlines a nursing assessment, diagnosis, plan of care and interventions for a patient presenting with weakness, fever, decreased urine output and inability to tolerate oral fluids due to nausea, vomiting and diarrhea, resulting in a diagnosis of fluid volume deficit. The plan is to monitor the patient's intake and output, increase IV fluids, monitor for signs of dehydration and hypernatremia, and normalize lab results through correction of the fluid deficit over 8 hours of nursing intervention.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Download as docx, pdf, or txt
    of 2

    ASSESSMENT NURSING DIAGNOSIS PLAN OF CARE INTERVENTION RATIONALE EVALUATION

    Subjective Data: Fluid Volume Deficit After 8 hours of nursing - Record Intake and - Accurate records are - After 8 hours of
    related to nausea, intervention patient will output needed in assessing the nursing intervention
    “Nanghihina ako pag vomiting and diarrhea manifest relief on patient’s fluid balance. patient manifested
    kumikilos para akong as manifested by weakness, able to Increase strength
    pagod na pagod tapos weakness, fever, tolerate fluid intake, - Increase fluid intake - Patient is not able to during movement, Able
    parang nilalagnat ako decreased urine output, and temperature will be through IV as tolerate fluid intake to have sips of water as
    tapos nahihirapan ako increased urine specific lowered to normal body prescribed. orally due to nausea tolerated and was able
    uminom tubig kasi gravity and increase temperature of and vomiting. to discuss the
    naduduwal at nasusuka serum sodium. 36.5 °C – 37.5 °C. - Increasing fluid intake symptoms of deficit of
    ko at nag tatae pa” as Laboratory data will be helps in correcting fluid volume that would
    verbalized by the normalized to: Urine Specific Gravity help the patient calling
    patient. Urine specific gravity: and Increase Urine a Health care provider
    1.005 to 1.030 and output normalizing as necessary.
    Objective Data: Serum Sodium level: serum sodium level as
    Vital Signs: 135 – 145 mEq/L well. Vital signs:
    BP: 130/90 - Weigh daily and - For assessing fluid BP: 120/80 mmhg
    HR: 86 BPM monitor trends. balance. HR: 75 BPM
    RR: 24CPM - Monitor for - Hypernatremia can RR: 19 CPM
    TEMP: 38.6°C neurologic and create hypertonic Temperature:
    neuromuscular vascular space causing 36.5 °C – 37.5 °C.
    PHYSICAL EXAM: manifestations of water to transfer out
    HT: 5’3 hypernatremia. from the cells Loose stool: Absent
    WT: 166LBS manifested by Urine output: Normal
    neurologic symptoms 30ml/Hour
    DIAGNOSTIC DATA: such as lethargic,
    URINE SPEC. GRAVITY: seizures and irritability. Laboratory Data:
    1.0357 - Monitor for cardiac - Low fluid volume Urine specific Gravity:
    SERUM NA: 155mEq/L manifestations of makes the heart to 1.005 to 1.030
    CXR: NEGATIVE hypernatremia. respond increasing the Serum Sodium level:
    heart rate to 135 – 145 mEq/L
    compensate and can
    lead to increase blood
    pressure, tachycardia
    and orthostatic
    hypotension.
    - Give oral medication - Controlling loose stool
    for consecutive loose helps in preventing
    stool as prescribed. further fluid loss.

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