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    NCP 3 - Deficient Fluid Volume

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    Krishelle Kate Pannig
    This nursing care plan addresses fluid volume deficit in a patient presenting with low blood pressure, rapid heart rate, rapid breathing, and fever. The long term goal is for the patient to maintain normal fluid volume within 2 hours. Short term goals include maintaining normal vital signs and body temperature within 1 hour. Nursing interventions include monitoring and documenting vital signs, temperature, and ABG levels to ensure oxygen saturation is maintained above 90%. The plan aims to restore hydration and prevent complications like hypotension, tachycardia, and respiratory failure.

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    NCP 3 - Deficient Fluid Volume

    Uploaded by

    Krishelle Kate Pannig
    10 views4 pages
    This nursing care plan addresses fluid volume deficit in a patient presenting with low blood pressure, rapid heart rate, rapid breathing, and fever. The long term goal is for the patient to maintain normal fluid volume within 2 hours. Short term goals include maintaining normal vital signs and body temperature within 1 hour. Nursing interventions include monitoring and documenting vital signs, temperature, and ABG levels to ensure oxygen saturation is maintained above 90%. The plan aims to restore hydration and prevent complications like hypotension, tachycardia, and respiratory failure.

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    This nursing care plan addresses fluid volume deficit in a patient presenting with low blood pressure, rapid heart rate, rapid breathing, and fever. The long term goal is for the patient to maintain normal fluid volume within 2 hours. Short term goals include maintaining normal vital signs and body temperature within 1 hour. Nursing interventions include monitoring and documenting vital signs, temperature, and ABG levels to ensure oxygen saturation is maintained above 90%. The plan aims to restore hydration and prevent complications like hypotension, tachycardia, and respiratory failure.

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    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Download as docx, pdf, or txt
    10 views4 pages

    NCP 3 - Deficient Fluid Volume

    Uploaded by

    Krishelle Kate Pannig
    This nursing care plan addresses fluid volume deficit in a patient presenting with low blood pressure, rapid heart rate, rapid breathing, and fever. The long term goal is for the patient to maintain normal fluid volume within 2 hours. Short term goals include maintaining normal vital signs and body temperature within 1 hour. Nursing interventions include monitoring and documenting vital signs, temperature, and ABG levels to ensure oxygen saturation is maintained above 90%. The plan aims to restore hydration and prevent complications like hypotension, tachycardia, and respiratory failure.

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    Saint Paul University Philippines

    Tuguegarao City, Cagayan 3500

    School of Nursing and Allied Health Sciences


    College of Nursing

    NURSING CARE PLAN

    NCP #3
    ASSESSMENT NURSING BACKGROUND GOAL AND NURSING INTERVENTIONS EVALUATION
    / DIAGNOSIS KNOWLEDGE OBJECTIVES AND RATIONALE
    CUES
    Objective: Fluid Volume Deficient Fluid Volume is a NOC: Hydration NIC: Hypovolemia Management
    Deficit decreased intravascular,
    interstitial, and/or Long Term Goal: Long Term Goal:
    Vital signs:
    intracellular fluid. This - After 2 hours of - After 2 hours of
    BP - 90/60
    HR – 130 refers to dehydration and nursing intervention, nursing intervention,
    the patient will be able the patient was able to
    RR – 27 water loss alone without
    to maintain fluid maintain fluid volume
    Temp. – 38.2. a change in sodium.
    volume at a functional at a functional level as
    th
    (Nanda,15 edition) level as evidenced by evidenced by
    SpO2 60%
    individually adequate individually adequate
    Deficient Fluid urinary output with urinary output with
    ABG result: Volume (also known as normal specific gravity, normal specific
    pH-7.6, Fluid Volume Deficit stable vital signs, moist gravity, stable vital
    PaO2-120 (FVD), hypovolemia) is a mucous membranes, signs, moist mucous
    mmHg, state or condition where good skin turgor, membranes, good skin
    PaCO2 - 31 the fluid output exceeds prompt capillary refill, turgor, prompt
    mmHg, and the fluid intake. It occurs and resolution of capillary refill, and
    HCO3 - 25 when the body loses both edema. resolution of edema.
    mmol/L water Short Term Goal:
    and electrolytes from the
    After 1 hour of
    ECF in similar
    nursing intervention,
    Subjective: N/A proportions. Short Term Goal:
    the patient was able
    (Nurseslabs.com) After 1 hour of nursing to:
    intervention, the patient
    will be able to:
    1. Maintain vital
     Monitor and document vital signs and there
    1. Maintain a were no
    signs, especially BP and HR.
    normal vital A decrease in circulating abnormal vital
    sign. blood volume can cause signs reported.
    hypotension and tachycardia.
    Alteration in HR is a
    compensatory mechanism to
    maintain cardiac output.
    Usually, the pulse is weak and
    irregular if electrolyte
    imbalance also occurs.
    Hypotension is evident in
    hypovolemia.

    2. Have a normal
    body
     Monitor and document temperature of
    temperature. 36.1°C to
    Febrile states decrease body 37.2°C.
    fluids by perspiration and
    increased respiration. This is
    known as insensible water 3. Monitor
    loss. ABG’s and the
    client
     Monitor ABGs for changes to maintains
    prevent respiratory failure. ABGs and
    Oxygen saturation should be normal oxygen
    kept at 90% or greater saturation of
    (preferably 94% or higher, but 95%-100%
    this will depend on the
    patient’s medical history).

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