ASSESMENT DIAGNOSIS SCIENTIFICEXPLANATIONPLANNING INTERVENTION RATIONALE EVALUATIONSubjective:
“Okay na ako.”
- received pt. lyingon bed ĉ ongoingIVF of PNSS 1L torun for 12˚ @850cc level,infusing well to left- conscious andcoherent-ambulatory- ĉ non-productivecough- ĉ good skin turgor-ĉ good capillaryrefill- on soft diet- ĉ good appetite,consumed all foodserved- ĉ presence of active bowelsounds in theabdomen- voiding freely ĉyellowish urineoutput- afebrileRisk for fluidvolume deficitrelated toexcessive loss of fluids andelectrolytesWhen there isinsufficient fluidintake, andexcessive fluid lossfrom vomiting, anddiarrhea itindicatesimbalance in fluidvolume in whichthe body can’tcompensate by anadequate intake of water. Decreasedvolume in theintravascularcompartment iscalledhypovolemia.Because watermoves freelybetween thecompartments,extracellular fluiddeficit causesintracellular fluiddeficit (cellulardehydration),which leaves thecells withoutadequate water tocarry on normalfunction.Within the 8˚shift, the clientwill not exhibitsigns andsymptoms of fluidvolume deficit.
- establish rapport- assess skin turgorand oral mucousmembrane- monitor and record I& O balance beingaware of insensiblelosses- weigh client andcompare with recentweight history-monitor vital signs- encourage increaseoral fluid intake- note increaselethargy,hypotension, andmuscle cramping
- regulate IVF asordered-administer diureticsand anti-emetics asprescribe- to facilitatecooperation as wellas to gain pt’s trust- to note presence of dehydration-to ensure accuratefluid replacementtherapy- to evaluatechanges as relatedto fluid status- BP,RR, PR oftenincreases wheneither fluid deficit orexcess is present- to facilitatehydration- electrolyteimbalances may bepresent- to assure that thebody receivesaccurate amount of fluids andelectrolytes- to regain fluidvolume balanceGoal met.Within the 8˚,the clientexhibited nosigns andsymptoms of fluid volumedeficit AEB goodskin turgor andmoist oralmucousmembranes.