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NURSING CARE PLAN

Nursing Scientific Nursing

CUES Nursing Objective Scientific Explanation Evalua
Diagnosis Explanation Intervention
Subjective: Imbalance Imbalanced -Establish dietary -To establish -Provide comparative The goa
- N/A nutrition, less nutrition: Less pattern with minimum weight baseline for effectiveness met.
than body than body calorie intake gain and daily of the therapy
requirement requirements adequate to nutritional The
Objective: related to intake of regain/maintain requirement nutritiona
inadequate nutrients appropriate -to provide diet -it will be more effective status
Height: 71 cm food intake insufficient to weight with substitution, for providing food in quite imp
Weight: 4.2 kgs meet metabolic administer enjoyable manner and in
needs. -Demonstrate nutritional diet treating malnutrition assessm
BMI: 8.3 weight gain to the with
clients expected supplementary
range food.
-this enhance
-To provide small manipulation in eating,
frequent diet with body adjustment and
consistence likely for preferred food.
approach with
pleasant
environment and
selectiveness
 Nursing Nursing Scientific
CUES Scientific Explanation Nursing Objective Evaluat
Diagnosis Intervention Explanation
Subjective: Risk for fluid Decreased After 1 week of - Assess the -This is the After 1 w
N/A volume deficit intravascular, interstitial, nursing intervention, vital signs and indicator of nursing
related to and/or intracellular fluid. patient will not capillary refill circulatory intervention
Objective: excessive loss experience fluid and skin turgor. volume patients s
This refers
volume deficit as has a poo
of fluid to dehydration, water evidenced by: turgor, and
Poor skin turgor associated with loss alone without - Normal skin
-Monitor the dry. Goal w
Skin looks dry vomiting and/or change in sodium. turgor amount and -Dehydration met.
diarrhea. Deficient fluid volume is - Moist mucous type of fluid results in
a state or condition membrane intake(oral electrolyte
where the fluid output - Stable weight rehydration imbalance so,
exceeds the fluid intake.
solution) output the monitoring
measuring helps to identify
It happens when water
accurately and the alteration in
and electrolytes are lost
replacing it with electrolyte
as they exist in normal
fluid intake. balance.
body fluids. Common
sources of fluid loss are
the gastrointestinal
tract, polyuria, and
increased perspiration.
Risk factors for FVD are
as follows:
vomiting, diarrhea, GI
suctioning, sweating,
decreased intake,
nausea, inability to gain
access to fluids.

Nursing Nursing Scientific

CUES Scientific Explanation Nursing Objective Evaluat
Diagnosis Intervention Explanation
 Subjective: Risk for "the state in which an Short Term: -Promoting -It helps to prevent Short Term
N/A infection related individual After 30 minutes hygienic the communicable After 30 m
to tissue is at risk to be invaded of nursing measures and disease cause by of n
Objective: by an opportunistic or intervention
destruction pathogenic
intervention, general poor hygiene.
parents we
secondary to agent (virus, fungus, parents should cleanliness
RR: 31 to know
CR: 131
colostomy bacteria, know the importance
T: 36.6 protozoa, or importance of -avoid exposure hygienic
other parasite) hygienic to cold and measures
from endogenous or measure when infection cleaning
exogenous sources" cleaning the colostomy
colostomy bag of -maintain patient.
patient. aseptic
technique and Long term:
Long term: hand washing week of n
After 1 week of practices during intervention
patient wa
nursing care
to becom
intervention will from any
be free from any and sympt
signs and having infe
symptoms of
infections.

Lab Result

LABORATORY TEST RESULT NORMAL VALUE SIGNIFICANCE

 Sodium 136.20 mmol/L 135-145 mmol/L -Within normal range
Potassium 3.48 mmol/L 3.5-5.1 mmol/L -Low potassium
(hypokalemia) refers to a
lower than normal potassium
level in your bloodstream.
Potassium is a chemical
(electrolyte) that is critical to
the proper functioning of
nerve and muscles cells,
particularly heart muscle
cells.
-Vomiting or diarrhea or both
can result in excessive
potassium loss from the
digestive tract.
Ionized Calcium 0.96 mmol/L 1.15-1.33 mmol/L -If you have low levels of
ionized calcium in your
blood, it can indicate:
-hypoparathyroidism,
which is an underactive
parathyroid gland
-inherited resistance to
parathyroid hormone
-malabsorption of
calcium
-a vitamin D deficiency
-osteomalacia or rickets,
which is a softening of
the bones (in many
cases due to a vitamin D
deficiency)
-a magnesium deficiency
-high phosphorus levels
-acute pancreatitis,
which is an inflammation
of the pancreas
-kidney failure
-malnutrition