NURSING CARE PLAN
Name: Celis, Mike Joshua C.
Age: 11 years old
Birthday: March 15, 2010
Address: Dagohoy, Inabanga, Bohol
Religion: Roman Catholic
Civil Status: Single
Assessment
Defining
Characteristics
Subjective Data:
“Dali ra ko
uhawon kon magbike kariyo ug uga
akong baba.”, as
verbalized by the
patient.
Objective data:
-
Dry or sticky
mouth
Dry skin
Decreased
urine output
Nursing
Diagnosis
Negative fluid
balance causing
dehydration as
evidenced by
dry mouth and
skin, decreased
urine output and
thirst.
Gender: Male
Chief Complaint: Dehydration
Weight: 43 kgs
Height: 4”9’
Diagnosis: Risk for Fluid Volume Deficiency (Hypovolemia)
Scientific Analysis
Dehydration happens
when the body doesn’t
have much water as it
needs. Without enough,
the body can’t function
properly. You can have
mild, moderate, or severe
dehydration depending on
how much fluid is missing
from your body. If you
don’t eat and drink
enough, you can get
dehydrated.
Plan of Care
(Planning)
Short term:
Nursing Intervention
(Implementation)
Independent:
After 8 hours of
nursing intervention,
the patient will be
able to demonstrate
adequate hydration
as evidenced by
adequate intake of
water.


Long term:
After 2 – 3 days of
nursing intervention,
the patient may show
Reference: What is
urinary output within
Dehydration? What
normal ranges,
Causes It? (2017, May
hydrated skin and
26). WebMD.
https://www.webmd.com/a- mouth.
to-z-guides/dehydrationadults
Monitor vital signs.

Promote increase in
fluid intake.

 Encourage to eat
foods with high fluid
content.
 Assess color and
amount of urine.
 Assess skin turgor

and mucous
membranes
 Monitor fluid output
and intake.
 Promote comfortable
environment.

Dependent:

Start oral and
IVF rehydration
therapy as
indicated.
Rationale
Determine the
degree of
dehydration.
Provides the
best assessment
of current fluid
status and
adequacy of fluid
replacement.
Maintain
hydration, avoid
overheating
which could
promote further
fluid loss.
Prevent injury
from dryness.
Evaluation

After
performing
all the
nursing
intervention,
the patient
maintained
fluid volume
at functional
level, well
hydrated,
intake is
equal as
output, and
normal skin
turgor and
mucous
membranes.