Mr. Bryson, 32 years
old, reporter. He always does jogging every morning together with his dog named
Bark. Bark is a Alaskan Malamute who loves to go outside so he always excited
about going out with Mr. Bryson to do jogging or shopping or visiting his
colleagues. Mr. Bryson also loves to go out with his dog because he feels
comfortable and he likes when people are looking at his dog saying good things.
Below is a sample of nursing care plan about deficient fluid volume of Mr.
Bryson.
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 loss may lead to severe dehydration that can cause
more severe complications.)
INTERVENTION
- Evaluate nutritional
status of Mr. Bryson and note his current intake and weight changes. Remember
that Mr. Bryson is an elderly patient who are often have his decreased thirst
reflex and may not aware of his water needs.
- Monitor Mr. Bryson's
vital signs regularly especially his blood pressure, take blood pressure with
him lying, sitting, and standing when possible. Also, monitor confusion of his
loss of ability to carry out usual activity, lethargy and dizziness. Confusion
is caused by sufficient dehydration due to his poor cerebral perfusion and
electrolyte imbalances. Check acute confusion.
- Monitor Mr. Bryson's
urinary output so that you could accurately determine the fluid replacement he
needs. Administer him fluids and electrolytes as indicated, oral fluid intake
is indicated in patients like him with mild dehydration. Provide Mr. Bryson
beverages and fluids with high fluid content and encourage him 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 to Mr. Bryson,
stop or lower his infusion and notify the physician. Maintain accurate input
and output and instruct Mr. Bryson and his 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 Mr. Bryson 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.
For more samples of
nursing care plan you are free to check it out in our NCP LIST page.
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