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Example of Nursing Care plan for Deficient fluid volume
Nursing Diagnosis:
Deficient fluid volume related to vomiting and diaphoresis as evidenced by tachycardia, urine concentration and poor skin turgor.
Assessment Cues:
Subjective data:
- “ I feel very thirsty all day but I can’t tolerate fluids because of nausea and vomiting that I have”
- “ My urine become dark yellow ”
Objective Data:
- Tachycardia: 105 beats/min
- Tachypnea: 30 cycle/min
- Poor skin turgor
- K+: 2.9 mEq/l
- Increased Urea level: 0.77 mg/dL
- Increased Creatinine level: 22mg/L
- Concentrated urine
- Urine output > 60ml/h
Planning and Outcome:
Short term:
- The patient will experience relief from nausea and vomiting in 2-4 hours
- The clients’ fluid intake and output will be balanced in 12 to 24 hours.
Long term:
- The patient lab value will be within normal limits prior to discharge.
Nursing Interventions and Rationale:
| NURSING INTERVENTIONS | RATIONALE |
| Independent: | |
| – Assess and document amount, color, and characteristics of vomitus. | – Determine fluid replacement |
| – Measure and document vital signs every hour | – Monitor patient’s status |
| – Assess skin turgor | – Indicates hydration status |
| Dependent: | |
| – Administer antiemetic drugs | – Prevent further fluid loss |
| – Administer IV fluids with flow rate as prescribed | – Insure a good solution replacement and prevent over rehydration |
| – Administer IV potassium as prescribed | – Low potassium levels are dangerous and the patient has hypokalemia |
Evaluation:
Goal met:
- The patient’s nausea and vomiting stopped after administering antiemetics.
- The patient’s vital signs improved HR=80, RR= 17 and urine output > 60ml/h.
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