ASSESSMENT NURSING PLANNING INTERVENTI RATIONALE EVALUATION

DIAGNOSIS ONS

Subjective: Fluid volume Within 8 hours Independent: After 8 hours of

deficit related to of rendering rendering
“Dalawang araw -Urge the patient -Oral fluid
vomiting quality nursing quality nursing
na pong nag to drink the replacement is
secondary to interventions, interventions,
susuka ang anak prescribed indicated for
AGE as the client will: the client is able
ko, nurse” as amount of fluid. mild fluid deficit
evidenced by to:
verbalized by -have normal and is a cost-
vomiting,
the mother of skin turgor effective method -have improved
decrease fluid
the patient. for replacement skin turgor
intake, sunken -moist mucous
treatment.
Objective: eyeballs, dry membrane -moist mucous
mucous -Aid the patient -Dehydrated membrane
-Vomiting membrane and -HR within
if they cannot patients may be
decreased skin normal range -HR was
-Sunken eye eat without weak and unable
turgor. (80-130) normalized from
balls assistance, and to meet
137 to 130
-absence of encourage the prescribed
-Dry mucous family or SO to intake
vomiting -reduced
membrane Fluid volume assist with independently. occurrence of
deficit (also feedings as vomiting.
-Weakness
known as necessary.
-Decreased skin deficient fluid Goal was
-Patient may
tenting volume or -If the patient partially met.
have a reduced
hypovolemia) can tolerate oral
VS taken as describes the sense of thirst
fluids, give what
follows: loss and may require
oral fluids the
of extracellular continuing
patient prefers.
-HR: 137 fluid from the reminders to
Provide fluid
body. When left drink.
-RR: 32 and straw at
untreated, bedside within
-TEMP: 36 severe fluid
easy reach.
volume deficit
-02: 99% Provide fresh
can lead to renal
failure, heart water and a
failure, general straw.
organ failure -A fluid deficit
- Emphasize the can cause a dry,
(from lack of
importance sticky mouth.
oxygen) and
of oral hygiene. Attention to
death.
mouth care
promotes
interest in
drinking and
reduces the
discomfort of
dry mucous
membranes.
-Provide a -Drop situations
comfortable where patients
environment by can experience
covering the overheating to
patient with prevent further
light sheets. fluid loss.

-Educate the -Enough

guardian about knowledge aids
possible causes the guardian in
and effects of taking part in
fluid loss or their plan of
decreased fluid care.
intake.
-Emphasize the -Increasing the
relevance of guardian’s
maintaining knowledge level
proper nutrition  will assist in
and hydration. preventing and
managing the
problem.
Dependent:
-Administer
parenteral fluids -Fluids are
as prescribe necessary to
maintain
-Administer hydration status.
medications as Determination
ordered. of the type and
amount of fluid
to be replaced
and infusion
rates will vary
depending on
clinical status.