Assessment Diagnosis Scientific Objectives Intervention Rationale Evaluation
Explanation
S: “medyo nasususka Deficient Fluid After 8 hour of Assess vital Vital signs After 8 hour of nursing
po ako.” volume less than Frequent watery nursing signs, noting changes such as intervention the client
body stool intervention the low blood increased heart was able to:
O: requirements client will be able pressure, rate,
Concentrated related to Hyperactive bowel to: sever decreased blood Short term:
urine dark passage of watery sounds hypotension, pressure, and Maintained
yellow stool, nausea and Short term: rapid increased adequate fluid
Weakness vomiting as watery and Maintain heartbeat temperature volume at a
Dry skin evidenced by greenish in color adequate and thread indicate functional level as
Dry mucous weakness and fluid volume peripheral hypovolemia. Hyp evidenced by
membrane poor skin turgor. Introduction of at a pulses otensive and adequate fluid
Pale bacteria into the GI functional increased pulse volume and
conjunctiva tract level as rate can be an electrolyte
Pale nail beds evidenced indication that balance as
Capillary refill Release of by adequate patient is evidenced by
more than 3 bacterial toxins fluid volume dehydrated. urine output
seconds and greater than 20 ml
Soft and Disrupts the electrolyte per hour
watery stool mucus lining of the balance as Observe and Dark greenish
Vitals signs stomach evidenced measure brown indicate
BP 110/80 by urine urinary concentrated.
RR 20 Release of HCl output output
PR 63 cause gastric greater than (hourly/24 Long term
Temp 36.4 irritation 20 ml per hour total) The patient will
hour Note color manifests weight
Increase gastric gain
motility/peristalsis Showed no signs
of dehydration
Increase gastric
motility Long term Continue Indicates
The patient monitoring excessive fluid
Frequent will manifest intake and loss or resultant of
defecation weight gain output(accur dehydration.
Shows no ately), Accurate records
Increase loss of signs of character, are critical in
water and dehydration and amount assessing the
electrolytes of stools, patient’s
vomiting and fluid balance
Diarrhea bleeding
Reference:
Medical nursing Monitor for Potassium is vital
by Gettrust neurologic electrolyte for
and skeletal and
neuromuscul smooth muscle
ar manifestati activity.
ons
of hypokalem
ia (e.g.,
muscle
weakness,
lethargy,
altered level
of
consciousne
ss)
Provide Oral hygiene can
oral hygiene. increase patient’s
By means of appetite for eating
teaching and interest in
patient drinking essential
to brush amount of fluid
teeth thrice a
day or every
after meal.
(Use
soft bristle to
prevent
bleeding
episodes
Provide To prevent injury
frequent eye from dryness
care
Encourage Oral fluid
patient to replacement is
drink indicated for mild
fluid deficit
Reference:
(Nursing Care Plans, 9th
Edition, Doenges,
Moorhouse & Murr,
p.325-326 2014)
Health Teaching:
To replace the lost
Instruct the
fluids and
family to give
electrolytes orally
the client a
drink 2-3
liters/day
Collaborative:
Administer
Intravenous fluids
as prescribed.
Lactated To deliver fluids
Ringers accurately and at
125cc/hr desired rates
Oral To rehydrate the
Rehydration
Solution patient
Still for Laboratory
result:
CBC with APC Provides
information about
Monitor
hydration and
laboratory organ function.
studies: Significantconseq
Hgb/Hct, uences to
electrolytes, systemic function
protein are possible as a
result of fluid
shifts,
hypovolemia,
hypoxemia,
circulating toxins
Reference:
(Nursing Care Plans, 9th
Edition, Doenges,
Moorhouse & Murr,
p.325-326 2014)