Nursing Care Plan

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Medical Diagnoses: Deficient Fluid Volume, Reduced Fluid Intake and Physical Immobilization

Assessment

Nursing DX/Clinical Problem

Client Goals/Desired Outcomes/Objectives

Nursing Interventions/Actions/Orders and Rationale

*I

Evaluation

Goals

Interventions

   

   

   

   

   

   

   

Subjective

Patient admits that she is never thirsty. Patient said that her mouth is sometimes dry. Patient only had a small glass of water (100cc)  at dinnertime and did not want to drink anymore. Patient said she does not urinate very much. Pt states that she cannot move her lower legs and has a lot of trouble getting out of wheelchair.

   

Objective

Patient has poor skin turgor in both hands. Patient has increased BUN on lab count. Patient had very dried and warm skin to touch Patient did not urinate during shift. Patient has a history of PVD. Patient stays in wheelchair all day and is incontinent and wears a brief. Patients skin is currently intact but very fragile.

Problem

Deficient Fluid Volume

   

Risk for Impaired Skin Integrity

   

 

 

Long Term:

Client will maintain elastic skin turgor, moist tongue and mucous membrane; and orientation to person, place and time over the next month.

   

Patient will report altered sensation or pain at risk areas over the next month.

   

The nursing student will monitor the elderly client for deficient fluid volume carefully, noting new onset of weakness, dizziness, or dry mouth with longitudinal furrows on the tongue. EB: The elderly are predisposed to deficient fluid volume because of decreased fluid in body, decreased thirst sensation, and decreased ability to concentrate urine

(Suhayda & Walton, 2002).

   

The nursing student will monitor skin condition at least once a day for color or texture changes, dermatological conditions or lesions. EB: Systematic inspection can identify problems early (Krasner, Rodeheaver & Sibbald, 2001).

   


Nursing student checked these areas of concern at the end of the shift and noticed that the patients skin turgor was poor. Patient had a moist tongue along with mucous membranes. Patient was oriented to the person, place and time.

   

Nursing student performed a complete skin assessment on patient and during palpation patient did not show any alterations in pain or sensation.

Nursing student asked the client if she was experiencing any dizziness or weakness and patient responded that she was not experiencing any signs or symptoms of either. Patient said that she had a dry mouth but upon assessment nursing student noticed moist mucous membranes and tongue.

   

During skin assessment nursing student did not note any changes in patients skin texture or color. Nursing student did not see any areas of concern on skin.

R/T

Reduced Fluid Intake

   

Physical Immobilization

   



Short Term:

Patient will maintain urine output more that 1300mL/day (or at least 30mL/hour) over the next three shifts.

   

Patient will verbalize a personal plan for preventing impaired skin integrity by the end of shift.

The nursing student will incorporate hydration into daily routines (e.g., extra glass of fluid with medication or social activities. EB: Verbal prompting ad offers of preference fluids resulted in increased fluid intake among nursing home residents (Simmons, Alessi & Schnell, 2001).

   

The nursing student will help patient use lotions and moisturizers as part of a personal plan to prevent impaired skin integrity. EB: To prevent skin from drying out, especially in the winter (Sibbald & Cameron, 2001).

   

Nursing student did not get the chance to assess the urine output due to the fact that the patient did not urinate at all during the shift. Nursing student will check on this issue next visit.

   

Nursing student and patient came up with a plan to apply lotion or moisturizer that was available in her own room.

Nursing student encouraged patient to drink another cup of water at dinner and patient responded by saying that she was not thirsty. Nursing student also asked patient if she wanted a different beverage and patient said no. Nursing student also encouraged the intake of fluids by bringing water to patient during assessment.

   

The nursing student did not apply any topical lotion or moisturizer to skin during this shift. The nursing student will get this intervention approved and plan on doing this during next shift.


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