Nusing Care Plan (NCP) for deydration & fluid volume deficit: The free nursing care plan example below includes the following conditions: Fluid Volume Deficit, Gastrointestinal (GI) Bleed, Dehydration, Hemorrhage, Hypotension, and Abdominal Pain as the main problems identified in the patient assessment.
What are nursing care plans? How do you develop a nursing care plan? What nursing care plan book do you recommend helping you develop a nursing care plan?
This care plan is listed to give an example of how a Nurse (LPN or RN) may plan to treat a patient with those conditions.
Important Disclosure: Please keep in mind that these care plans are listed for Example/Educational purposes only, and some of these treatments may change over time. Do not treat a patient based on this care plan.
Care Plans are often developed in different formats. The formatting isn’t always important, and care plan formatting may vary among different nursing schools or medical jobs. Some hospitals may have the information displayed in digital format, or use pre-made templates. The most important part of the care plan is the content, as that is the foundation on which you will base your care.
Sample Care Plan: Fluid Volume Deficit, Gastrointestinal (GI) Bleed, Dehydration, Hemorrhage, Hypotension, and Abdominal Pain
If you want to view a video tutorial on how to construct a care plan in nursing school, please view the video below. Otherwise, scroll down to view this completed care plan.
Scenario: |
| A 45 year old male comes in from the ER with complaints of abdominal pain that started yesterday morning. He also complains of frequent dark tarry stool that has lasted for 3 days and coffee ground looking emesis that just started yesterday. He states he feels dizzy and very weak. The pt looks pale and diaphoretic. His mucous membranes are dry. Current vital signs are: Temp 98.8, BP 99/62, HR 111, O2 Sat 98% and pain rating of 8 on 1-10 scale. Patients medications include Aspirin 325 mg PO daily, Lisinopril 2.5 mg PO Daily, Liptior 10 mg PO at bedtime, and Coumadin 5 mg Daily. Lab work shows the following: Hgb 7.4, Hct 35%, INR 6.7. |
Nursing Diagnosis: |
| Fluid Volume Deficit related to hemorrhage as evidence by dry mucous membranes, BP 99/62, HR 111, Hgb 7.4, coffee ground looking emesis, abdominal pain, INR 6.7, and frequent dark tarry stools. |
Subjective Data: |
| Abdominal pain that started yesterday morning, , frequent dark tarry stools that has lasted for 3 days, coffee ground looking emesis that started yesterday, feels dizzy and very weak. |
Objective Data: |
| Pt looks pale, diaphoretic, mucous membranes are dry, VS BP 99/62, HR 111, pain rating of 8 on 1-10 scale, Hgb 7.4, INR 6.7. |
Nursing Outcomes: |
| -Pt’s HGB will be greater or equal to 14 as evidence by lab values within 48 hours. -Pt’s input will be equal to output as evidence by shift I & O reports within 72 hours. -Pt’s mucous membranes will appear moist as evidence nursing documentation within 48 hours. |
Nursing Interventions: |
| -Pt will be transfused 2 units of Packed Red Blood Cells per MD order and HGB will be rechecked 1 hour after transfusion has completed. -Nursing will measure and accurately record patients input and output hourly. -Pt will be started on Normal Saline IV at 150 cc/hr for 24 hours per MD order and mucous membranes will be reassessed within 24 hours. |