DEFICIENT FLUID VOLUME (hyper/hypotonic) Nursing Care Plan

Deficient fluid volume is a condition where the fluid output exceeds the fluid intake and body electrolytes became imbalance as a result of dehydration, blood loss, vomiting or diarrhea which causes cells in our body to not function properly. Below is an example of nursing care plan for patients with deficient fluid volume.

ASSESSMENT

Subjective:

“I feel exhausted, I’m thirsty.” as verbalized by the patient.

Objectives:

The patient is pale, has dry mouth, dry skin and dry mucous membrane. Other objectives for the patient are decrease urine output, experiencing weight loss and confusion. Vital signs are taken and noted as follows: Body temperature is 38.1 degrees Celsius, blood pressure is 90/70 mmHg, pulse rate is 129 beats per minute, and respiratory rate is 20 cycles per minute. The client has fever as manifested by his/her body temperature which is above normal.

DIAGNOSIS

Deficient fluid volume related to exhaustion as manifested by increased pulse rate and dry skin and mucous membranes. (Exhaustion in this diagnosis refers to extreme physical tiredness.)

PLANNING

 After 4 hours of nursing intervention, the patient will maintain fluid volume at functional level as evidenced by stable vital signs, moist mucous membrane and good skin turgor. (We need to regain his/her fluid deficiency as soon as possible to prevent continuous fluid lossy may lead to severe dehydration that can cause more severe complications.)

INTERVENTION

Evaluate nutritional status and note the current intake and weight changes. Remember that clients with very young age cannot describe or verbalized thirst. While elderly patients are often have a decreased thrust relax and may not aware of water needs.

Monitor client's vital signs regularly especially blood pressure, take blood pressure with the client lying, sitting, and standing when possible. Also, monitor confusion of his/her loss of ability to carry out usual activity, lethargy and dizziness. Confusion is caused by sufficient dehydration due to poor cerebral perfusion and electrolyte imbalances.

Monitor urinary output so that you could accurately determine the fluid replacement needs. Administer fluids and electrolytes as indicated, oral fluid intake is indicated in patients with mild dehydration. Provide beverages and fluids with high fluid content and encourage the patient to limit intake of alcohol and caffeinated beverages that tend to exert a diuretic effect. Severe fluid deficiency can be manage through intravenous fluid infusion, administer blood products as prescribe by physician and regulate the intravenous flow rate. If symptoms of fluid overload manifest, stop or lower the infusion and notify the physician. Maintain accurate input and output and instruct the client and relatives in how to measure and record the input and output.

If diarrhea is present, administer anti-diarrheal medication as indicated. If vomiting is present, administer anti-emetic medication as prescribe. If the patient has regional enteritis, liquids and food containing sodium is restricted. 

EVALUATION

After 4 hours of nursing intervention, the patient has maintained fluid volume at functional level as evidenced by stable vital signs, moist mucous membrane and good skin turgor.

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FEAR Nursing Care Plan

The sample care plan about fear above is not the only way, you can create thousands of specific care plan about fear. In creating nursing care plan about fear, you must specify your focus. Example: fear of snakes.

Fear is a depensive mechanism in protecting oneself or response to perceived threat but if left unchecked, it can become disabling to the client's life.

ASSESSMENT

Subjective:

"I'm afraid of what will be the result of my operation," as verbalized by the patient.

Objectives:

The patient was diminished his/her self-esteem, he/she has loss competence and narrowed focus on the source of fear. Vital signs are taken and noted as follows: Body temperature is 36.5 degrees Celcius, blood pressure is 140/90 mmHg, respiratory rate of 22 cycles per minute, and pulse rate of 108 beats per minute. 

DIAGNOSIS

Fear related to possible unwanted result as evidenced by narrowed focus on the source of fear and increase pulse pressure. 

PLANNING

After 4 hours of nursing intervention, the patient will verbalize accurate knowledge of safety related to current situation. 

INTERVENTION

Identify sensory deficits that may be present such as vision or hearing impairment. Sensory deficits may lead to misinterpretation of the environment. Determine the client's age or his/her developmental level. This will help in understanding on usual or typical fears. Toddler often has different fears than adolescent or older people. Investigate client's reports of subjective experiences, which could be indicative of delusions or hallucinations. Note degree of incapacitation. Be alert to signs of denial and depression. Be alert to and evaluate potential for violence. Measure vital signs and physiological responses to situation.

Stay with the client more often to have someone else to be there because it provides client with desired support person that can diminished feeling of fear. Listen to the client's concern, it promotes atmosphere of caring and permits exploration of misperception. Acknowledge normalcy of fear, pain, despair, and give "permission" to express feelings appropriately. This promotes attitude of caring and opens door for discussion about feelings and addressing reality of situation. If necessary, provide presence or physical contact such as hugging, refocusing attention or rocking a child. These soothe fears and provide assurance.

Manage environmental factors such as loud noises, harsh lightning, changing of person's location or stranger in care. These can cause stress, especially to very young or to order individuals. Speak in simple sentences and concrete terms because it facilitates understanding and retention of information. Provide opportunity for questions and answer honestly to enhance sense of trust and nurse client relationship. Avoid arguing about client’s perceptions of the situation to limit conflicts when fear response may impair rational thinking. Encourage contact with a peer who has successfully dealt with a similarity fearful situation. This provides a role model and client is more likely to believe others who had similar experience. Enhances sense of control by identifying client's responsibility for the solutions while reinforcing that the nurse will be available for help if desired or needed. Check use of anti-anxiety medications and reinforce use as prescribed. Assist in identifying areas in which control can be exercised and those in which control is not possible, thus enabling client to handle fearful situations. Instruct in use of relaxation or visualization and guided imagery skills. Explain procedures within client's ability to understand and handle to prevent confusion and overload.

EVALUATION

After 4 hours of nursing intervention, the patient verbalized accurate knowledge of safety related to the current situation.

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FATIGUE Nursing Care Plan

Causative factors related to fatigue may be psychological such as stress, anxiety, boring lifestyle or depression. It is also maybe environmental (noise, lights, humidity, temperature) or situational (occupation, negative life events). But mostly fatigue is due to physiological such as increased physical exertion, sleep deprivation, pregnancy, disease states, and malnutrition. Below is a sample of nursing care plan for patients with fatigue.

ASSESSMENT

Subjective:

 “I’m so tired, I need some rest,” as verbalized by the patient.

Objectives:

The patient is lethargic and drowsy. He/she is not interested to his/her environment and he/she didn't want to socialize with others. Vital signs are taken and noted as follows: Body temperature is 36.5 degrees Celcius, blood pressure is 120/80 mmHg, respiratory rate is 17 cycles per minute, and pulse rate of 88 beats per minute.

DIAGNOSIS

Fatigue related to lethargy as manifested by lack of energy and disinterest in the surroundings. (Lethargy is a condition when a person is irritable, can't stay still and can't find his/her comfort).

PLANNING

After 8 hours of nursing intervention, the patient will report improve sense of energy.

INTERVENTION

Ascertain client’s belief of about what is causing the fatigue. Assess vital signs to evaluate the fluid status and cardiopulmonary response to activity. Determine presence of sleep disturbances because fatigue can be a  consequences of sleep deprivation. Interview parent or relatives regarding specific changes. Note daily energy patterns. Measure physiological response to activity: changes in blood pressure, heart rate and respiratory rate. Evaluate need for individual assistance. Established realistic activities with the client and encourage forward movement.

Instruct in methods to conserve energy such as sitting instead of standing during daily care, carry several small leads instead of big one, combine and simplify activity. Take frequent short rest breaks during activities and delegate task for assistance. Encourage use of activities device to conserve energy for other tasks. Avoid exposure to extreme temperature and humidity which can negatively impact energy level. Provide pleasurable activities. Discuss routines to promote restful sleep. Promote overall health measures: nutrition, adequate fluid intake and appropriate vitamin supplementation.

Note the age, gender and developmental stage, although, some studies show a prevalence of fatigue in adolescent girls, the condition may be present in any person at any age. Identify presence of physical and psychological conditions such as factors said above. Review medication regimen or use. Certain medications, including prescription (especially beta - adrenergic blockers), over-the-counter, herbal supplements, and combinations of drugs or substances, are known to cause and exacerbate fatigue. Note recent lifestyle changes, including conflicts (expanded responsibilities or job related conflicts); maturational issues such as adolescent with eating disorder); and developmental issues such as new parenthood, loss of spouse. Assess psychological and personality factors that may affect reports of fatigue level. Evaluate aspect of "learned helplessness" that may be manifested by giving up. This can perpetuate a cycle of fatigue, impaired functioning, and increased anxiety and fatigue. Obtain client descriptions of fatigue like lacking energy or strength, tiredness, weakness lasting over length of time. Note presence of additional concerns such as irritability, lack of concentration, difficulty making decisions, problems with leisure, relationship difficulties. These assist in evaluating impact on client's life. Rate client's fatigue from 1-10 and note its effects on ability to participate in desired activities. Discuss lifestyle changes or limitations imposed by fatigue state. Interview parent regarding specific changes observed in child or elder, this client may not be able to verbalize feelings or relate meaningful information. 

EVALUATION

After 8 hours of nursing intervention, the patient reported improved sense of energy.

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ADULT FAILURE TO THRIVE Nursing Care Plan

Adult failure to thrive is a person who has been a socially active, emotionally healthy and physically fit but are now a socially withdrawn, emotionally distress and physically atoned. There are three major factors of adult failure to thrive: Depression, major disease/degenerative condition, and ageing process. In pediatric patient, failure to thrive describes as a weight loss of more than 5%. Here we will share to you a sample of nursing care plan for patients who diagnosed as adult failure to thrive.

ASSESSMENT

Subjective

"I want don't want to live!" as verbalized by the patient.

Objective

I observed from the client that he/she had decreased in social skills. Social skills are the inability of a person to interact and communicate to others. The client also withdrawn him/herself to socialized with others. The client lacks on interest to almost everything or in apathy, he/she didn't want to eat and took a bath for almost a week so the client is self-care deficit.

Vital signs was taken and noted as follows: Body temperature is 35.8 C, blood pressure is 110/80 mmHg, respiratory rate is 16 cpm and pulse rate, 69 bpm. Three of his/her vital signs are normal, the body temperature, blood pressure, and respiratory rate while his/her pulse rate is below the normal rate.

DIAGNOSIS

You can use "Adult failure to thrive related to verbalized desire to death as manifested by social withdrawal and self-care deficit". Actually, saying "I don't want to leave", does not directly pertains to desire to death by rather the undesire to live.

PLANNING

After 4 hours of nursing intervention the patient will identify corrective and adaptive measures for individual situation. Why 4 hours? A patient who verbalized desire to death may attempt to suicide or will cause violent or inappropriate actions, so we need to accomplish our nursing care intervention as quick as possible.

INTERVENTION

The first thing you need to do is to get information about the patient's previous and current life situations. Find out changes and losses that may probably affects him/her. After that, identify also the expectations regarding the current condition. Determine the client's cognitive, perceptual ability and effect on self-care ability and use a collaborative and comprehensive assessment to determine the extent of limitations affecting about to thrive and potential positive interventions.

Encourage client to talk about and listen actively to the client's perception of problem. Discuss his/her concerns about feelings of loss and relationship between his/her feelings and current decline in well being. Have the client took enough time to talk everything he/she wants to say and just have time to listen to him/her. Encourage client, to talk about positive aspects of life and to keep a physically active as possible. Offer opportunities that enhance hopefulness for future. Encourage strengths and coping behaviors that the client used previously promote commitment to goals and plan which maximizing outcomes by assisting the client to develop goals for dealing with life or illness situation. In addition, you can assist client to join useful community resources such as support groups, social workers, home care and assistive care which can enhance coping assists with problem solving, and may reduce risks to client.

After the smooth conversations, develop a nursing care plan with client, to meet immediate needs for nutrition, safety and self-care ability. Another nursing care plan is needed immediately to target his/her nutrition since the client did not eat for a few days so that he/she will regain his/her health deficiency. To make it easy and effective, you can coordinate with the client and the nutritionist to identify specific dietary needs and creative ways to stimulate intake such as offering the client's favorite food, family's style meals and happy hour. You can include safety and regaining self-care ability in the interventions and actions.

EVALUATION

After 4 hours of nursing intervention, the patient identified the corrective and adaptive measures for the client's situation.

If you like nursing care plan right in your hand, I highly recommend this handbook Nursing Care Plans: Diagnoses, Interventions, and Outcomes, 8e to you. This book provides the latest nursing diagnosis and it is much cheaper than the other books (others are $66 above). Professors and professional nurses also recommend this book (you can check their reviews on comments' section). Get this book here to have a free shipping!

DEFICIENT DIVERSIONAL ACTIVITY Nursing Care Plan

Deficient diversional activity is a state when a person is experiencing decreased simulation from a particular activity. Deficient diversional activity may be due to long-term hospitalization, bedridden, fatigue, pain, and depression. Below is an example of nursing care plan for patients with deficient diversional activity.

ASSESSMENT

Subjective:

"I'm bored, I wish there is something I can do," as verbalized by the patient.

Objectives:

The patient is lethargic, inattentive, restless and lack of interest in eating. When you feel lethargic, you are sluggish and lacking of energy. It makes anything hard to be done when you are lethargic. Vital signs was taken and noted as follows: Body temperature is 36.8 degrees Celcius, blood pressure is 120/80 mmHg, respiratory rate is 16 cycles per minute, and pulse rate of 90 beats per minute. Only his/her respiratory rate is normal, his/her pulse rate is below normal range, the client's body temperature is above normal and also the blood pressure which is categorize as pre-hypertension. 

DIAGNOSIS

Deficient diversional activity related to boredom as manifested by lethargy and inattentiveness.

PLANNING

After 4 hours of nursing intervention, the patient will engage in satisfying activities within personal limitation. (Time frame may increase since this kind of deficiency does not overcome so easily and quick. It may gradually manage over time.)

INTERVENTION

You must determine the client's actual ability to participate in available activities. Review client's physical, cognitive, emotional, and environmental status. With this, it can validate reality of environmental deprivation when it's exists or considers potential for loss of desired diversional activities in order to plan for prevention or early interventions.

Note the age and the developmental level, gender, cultural factors, and the importance of a given activity in client's life in order to support client participation in something which promotes self-esteem and personal fulfillment.

After that, provide comparative baseline for assessment and intervention to check for any disability and illness in lifestyle. Establish therapeutic relationship and support hopeful emotions by acknowledging reality of situation and feelings of the client. Review history of lifelong activities and hobbies client has enjoyed. Discuss reasons client is not doing these activities now and determine whether client would like to resume these activities.

Continue appropriate actions to engage with concomitant conditions such as anxiety, depression poor grief because these interfere the individual's ability to engage in meaningful diversions activities. Encourage client to assist in scheduling required and optional activities such as if client's favorite TV show occurs at bathtime, reschedule bath for a later time. Structure the client's schedule according to his/her wishes for time of care, relaxation and promotional activities. This could increase client's sense of control. Refrain from making changes in schedule without discussing with client. This is very important for staff to be responsible in making and following through on commitments to client.

EVALUATION

After 4 hours of nursing intervention, the patient engaged in satisfying activities within his/her personal limitations.

If you like nursing care plan right in your hand, I highly recommend this handbook Nursing Care Plans: Diagnoses, Interventions, and Outcomes, 8e to you. This book provides the latest nursing diagnosis and it is much cheaper than the other books (others are $66 above). Professors and professional nurses also recommend this book (you can check their reviews on comments' section). Get this book here to have a free shipping!

DIARRHEA Nursing Care Plan

Diarrhea is condition when a person is experiencing hyperactive bowel movement and at least three loose liquid stools per day. The stool is usually loose and unformed. If your looking for nursing care plan for constipation, just search to our website and look for constipation nursing care plan. Below is an example of nursing care plan for patients with diarrhea.

ASSESSMENT

Subjective:

"I poop five times this day and my stomach is aching up until now, " as verbalized by the patient.

Objective:

I observed from the patient that his/her mouth is dry and had a poor skin turgor. His/her skin is cold and clammy. (Dry mouth and poor skin turgor is caused by dehydration or low body fluids secondary to diarrhea.) I scaled his/her pain 6/10 and the client's vital signs are taken and noted as follows: Body temperature is 36.2 degrees Celcius, blood pressure is 120/80 mmHg, respiratory rate is 16 cycles per minute and pulse rate of 110 beats per minute. Body temperature, respiratory rate and pulse rate are all normal, while his/her blood pressure is above normal and categorize as pre-hypertension.

DIAGNOSIS

Diarrhea related to five loose liquid stools in a day secondary to stomachache and cold clammy skin. (A cold clammy skin is a cool, moist and usually pale skin caused by cold sweat.)

PLANNING

After 4 hours of nursing intervention, the patient's normal pattern of bowel functioning will be reestablished and maintained.

INTERVENTION 

Factors associated with diarrhea maybe psychological (anxiety), situational such as using laxatives, alcohol abuse, or toxins and physiological such as inflammation, irritation, infectious process, and malabsorption. To assess these factors, ascertain onset and pattern of diarrhea, noting whether acute or chronic. Note the volume and the frequency of the stool. Also observe for presence, location and characterised of bowel sounds. And to eliminate causative factors, you can consider the following nursing interventions below:

Assist in treatment of underlying conditions such as infections, malabsorption syndrome and complication of diarrhea. Therapies can include treatment of fever, pain, and infectious agents.

In diarrhea, hydration and electrolyte imbalance must be addressed. Administer anti-diarrheal medications, as indicated to decreased gastrointestinal motility and minimizes fluid losses. Encourage oral intake of fluids containing electroless, such as juices, bouillon, or commercial preparations, as appropriate.

To maintain skin integrity, provide prompt diaper change and gentle cleansing because skin breakdown can occur quickly when diarrhea is present. Apply lotion or ointment as skin barrier and provide dry linen but expose perineum or buttocks to air.

To promote return to normal bowel functioning, increased fluids intake and return to normal diet as tolerated but avoid intake of irritating fluids. Recommend to the patient foods such as natural fiber, plain natural yogurt to restore normal bowel flora. Administer medications as ordered to treat infectious process, decrease motility, and absorb water. Also provide privacy during defecation and physiological support as necessary.

Remember to emphasize importance of handwashing to prevent spread of infectious causes of diarrhea such. Review causative factors and appropriate interventions to prevent recurrence of diarrhea. Review food preparation, emphasizing adequate coming time and proper refrigeration to prevent bacterial growth and contamination. Discuss possibility of dehydration and importance of proper fluid replacement.

EVALUATION

After 4 hours of nursing intervention the patient's normal pattern of bowel functioning was reestablished and maintained.

If you like nursing care plan right in your hand, I highly recommend this handbook Nursing Care Plans: Diagnoses, Interventions, and Outcomes, 8e to you. This book provides the latest nursing diagnosis and it is much cheaper than the other books (others are $66 above). Professors and professional nurses also recommend this book (you can check their reviews on comments' section). Get this book here to have a free shipping!

IMPAIRED DENTITION Nursing Care Plan

Impaired dentition is a state in which a person experiences a disruption in the integrity of his/her teeth. Our teeth serves a major role in the process of digestion. We use our teeth for biting, cutting, and chewing of food which is the start of the process of digestion so we need to take care of them. Here is a sample of nursing care plan for patients with impaired dentition.

ASSESSMENT

Subjective:

"My tooth is aching, "as verbalized by the patient.

Objectives:

I smell fowl odor from the patient's mouth as he/she is talking to me. This fowl smell of his/her breath is called halitosis. I also noticed that he/she has a tooth enamel discoloration and erosion. There are excessive plaque all over her/his teeth as well as dental carries. By observing him/her, I assume that he/she had a toothache because the patient is guarding his/her left, lower quadrant of his/her face. I've used pain scale to the patient and graded it 7/10.

Vital signs was taken and noted as follows: Body temperature is 35.5 degrees Celcius, blood pressure is 120/80 mmHg, respiratory rate is 17 cycles per minute, and pulse rate is 120 beats per minute. Body temperature, respiratory rate, and pulse rate are normal while his/her blood pressure is above normal and categorize as pre-hypertention.

DIAGNOSIS

Impaired dentition related to toothache as evidenced by tooth enamel discoloration and excessive plaque. (Toothache if a pain or soreness perceive by the person located within or around his/her tooth. Enamel is a hard substance that create a thin layer which covers the tooth).

PLANNING

After 4 hours of nursing intervention the patient's toothache will be diminished. (You can also add to your planning, "also his/her tooth enamel discoloration and excessive plaque will be treated."

INTERVENTION

The first you need to do is to evaluate the patient's current status of dental hygiene and oral health to determine the possible intervention and treatment needs. Note the absence of teeth and dentures and ascertain its significance in terms of nutritional needs and aesthetics. Document presence of factors affecting dentition such as chronic user of tobacco, coffee or tea because these drinks are tooth-stainer causes enamel damage. Bulimia and vomiting causes stomach acid goes to the mouth which destroys the tooth enamel.

Document or get a photo before treatment to provide pictorial baseline for future comparison or evaluation. Encourage the client to use soft toothbrush and use tap water, saline or diluted alcohol-free mouthwashers. If needed, administer antibiotics to treat oral or gum infection and analgesics of topical analgesics for
dental pain. In addition, encourage the patient to limit sugary foods and midnight snacks because as food left on teeth at night is more likely to cause cavities. Note: If the client is baby, regarding age-appropriate concerns, refrain from letting the baby fall asleep with milk or juice in bottle instead use water or pacifier during night. Avoid sharing the eating utensils among family members and don't forget to teach children to brush teeth while young.

For further management of the teeth, refer the client to appropriate care providers such as dental hygienists, dentists, periodontists or oral surgeon.

EVALUATION

After 4 hours of nursing intervention, the patient's toothache has been diminished. (If you add the tooth enamel discoloration and excessive plaque in your planning, just add to your evaluation, "and his/her tooth enamel discoloration and excessive plaque were treated)."

If you like nursing care plan right in your hand, I highly recommend this handbook Nursing Care Plans: Diagnoses, Interventions, and Outcomes, 8e to you. This book provides the latest nursing diagnosis and it is much cheaper than the other books (others are $66 above). Professors and professional nurses also recommend this book (you can check their reviews on comments' section). Get this book here to have a free shipping!