Example of a 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.

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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.