CUES NURSING RATIONALE PLANNING NURSING RATIONALE EVALUATION

DIAGNOSIS INTERVENTION
SUBJECTIVE: Fluid Volume Deficit Pathogens cause SHORT TERM >Establish rapport. >To gain the pt’s trust SHORT TERM GOAL:
r/t Active fluid tissue damage and GOAL: After 30 minutes of
Nung bago kami ma- volume loss AEB inflammation by After the shift, the rendered care, the
admit dito sa episodes of loose releasing endotoxins patient will be able >Monitor v.s. >To obtain baseline patient had restored
hospital, sumusuka watery stools that stimulate the to restore its data his body’s circulating
siya ng 3 beses at mucosal lining of the normal circulating fluids.
dumudumi ng intestine resulting body fluids >Assess & monitor the >To determine the
madami. in the greater I&O extent of dehydration
secretion of water LONG TERM LONG TERM GOAL:
OBJECTIVE: and electrolytes GOAL: After 1 day of
into the intestinal After 1 day of >Assess the level of >To determine the rendered nursing care,
> episodes of loose lumen. The active rendering nursing dehydration extent of dehydration the patient had
watery with secretions of care, the patient maintained optimum
particles stool, chloride and will able to normal circulating
moderate in amount bicarbonate ions are reestablish and >Give oral care >To clean the mouth & body fluids as
and scanty. the small bowel maintain body fluids avoid further drying evidence by negative
leads to the as will be of the lips BM per shift, lips are
> tenderness of the inhibition of sodium manifested by no longer dry, no
stomach re-absorption. To decrease BM per > Provide comfort >To prevent stress and tenderness of
balance the excess shift, lips are no measures anxiety that may stomach, intestinal
>weak in appearance sodium, large longer dry, no induce peristalsis colic is decrease and
amounts of protein intestinal colic and eye is no longer sunken
>dry lips rich foods fluids are no tenderness of >Encourage fluid > To replace loss of
secreted in the the stomach, and intake water and for
> eyes are slightly bowel’s ability to eye is not sunken. rehydration
sunken and teary reabsorb the fluid
and leading to
>c o2 inhalation via diarrhea. >Proper regulation of >Maintain hydration
facemask regulated IVF and electrolyte
at 4-5L balance

>c signs of
malnutrition