West Visayas State University

College of Nursing
La Paz, Iloilo City

NURSING CARE PLAN

Clustered Cues Nursing Rationale Outcome Nursing Rationale Evaluation
Diagnosis Criteria Interventions
Deficient fluid Decreased intravascular,
volume related to interstitial, and/or
fluid loss intracellular fluid. This The client will Assess for dry skin, To determine the degree
refers to dehydration maintain fluid poor skin turgor, of dehydration. It helps
without changes in sodium. volume at a peripheral edema, determine the amount
functional level muscle weakness, and route of rehydration
Infectious agents usually through etc. needed.
cause acute gastroenteritis. adequate oral
These agents cause and IV fluid
diarrhea by adherence, rehydration as Monitor vital signs; To obtain baseline data
mucosal invasion, evidenced by compare with for comparison during
enterotoxin production, moist mucous patient's previous evaluation. Postural
and/or cytotoxin membranes, BP = readings. Tale blood hypotension reflects a
production. These 110-90/70- pressure in lying, decrease in circulating
mechanisms result in 60mmHg and the sitting, standing volume.
increased fluid secretion resolution of positions when
and/or decreased edema by possible.
absorption. This produces
an increased luminal fluid Maintain an accurate To determine fluid
content that cannot be record of intake and balance.
adequately reabsorbed, output and correlate
leading to dehydration and with weight changes.
the loss of electrolytes and
nutrients. Measure and record Help differentiate
liquid stool as well as individual disease and
During diarrhea there is an the frequency of assesses the severity of
increased loss of water and bowel movement, each episode.
electrolytes in the liquid noting its
stool. Water and consistency and
electrolytes are also lost
through vomit, sweat, urine
and breathing.
If the body loses a
substantial amount of fluids
and is not quickly replaced,
the body starts to "dry up"
or get dehydrated.
Dehydration occurs when
these losses are not
replaced adequately and a
deficit of water and
electrolytes develops.
References:
Books
Diseases and Disorders: A
Nursing Therapeutic
Manual 2007 3rd Edition by
Sommers et al
appearance.
Provide frequent oral To prevent injury from
as well as eye care. dryness.
Start/administern To correct dehydration.
oral and IV fluid Oral therapy can
rehydration therapy rehydrate most patients.
as indicated. Oral rehydration therapy
is a strategy used to
reduce the severe
complications of
diarrheal disease
regardless of causative
agent. Intravenous
therapy is necessary for
rapid fluid replacement.
To limit gastric losses.

Nurse’s Pocket Guide 2008

11th Edition by Doenges et
al

Medical-Surgical Nursing
2004 7th Edition by Black &
Hawks

Brunner and Suddarth’s

Textbook of Medical-
Surgical Nursing 2004 10th
Edition by Smeltzer & Bare