ASSESSMENT DIAGNOSIS SCIENTIFIC PLANNING INTERVENTION Rationale EVALUATION

EXPLANATION
Subjective: Deficient fluid Short term: Independent: Short term:
Kasla kanayun nga volume After 4 hours of nursing Established rapport To gain patient and After 4 hours of
makain-inum ngem related to intervention and proper significant others nursing intervention
basit-basit lng met. excessive health teachings the Monitored and trust and proper health
as verbalized by the losses of client will manifest: recorded vital signs To obtain baseline teachings the client will
Mother. fluids through Proper hydration Assessed patients data manifested:
normal routes by the condition Proper
Objective: (vomiting and significant To be aware of hydration by
Restless and pale loose bowel others. patients condition the significant
in appearance. movement) Significant Monitored Intake and and to give others.
Defecated 3 times secondary to others will Output appropriate Significant
(in 7am-3pm inflammation identify factors Health Teachings done interventions others identified
shift) to a soft- of stomach affecting fluid to the mother as factors affecting
watery stool. and small balance. follows: fluid balance.
With poor skin intestine Recognize Encouraged to To ensure accurate Recognized
turgor interventions increase oral picture of fluid status interventions
With dry mucous that will avoid fluid intake of that will avoid
membrane further fluid the client. further fluid
With sluggish deficiency. Advised to offer To prevent deficiency.
capillary refill, 3 water rich foods dehydration and
sec. Long term: such as fruits- maintain hydration Long term:
After 3 days of nursing watermelon, status Still to be
With poor
interventions and papaya and evaluated
appetite, able to
proper health teachings apple If patient doesnt
consume only
the client will maintain Emphasized want to drink, it is
of the meal served
fluid volume at proper hygiene necessary to offer
Intake (7am-3pm) functional level as of the client. attractive foods
-OFI=550ml
evidenced by: especially for
-IVF=300ml
Intake and Collaborative: toddlers
-TOTAL: 850ml
Output is Administer
Output (7am- normalized or intravenous fluid as
3pm) equalized To avoid other
prescribed
-Urine: 650ml Good skin turgor complications
-Stool: 3-4tbsp. in Moist mucous regarding poor
3 episodes or 45- membrane hygiene and prevent
60ml reoccurrence of the
Well formed
-Vomitus: 5 tbsp disease.
stool and normal
or 75ml amount.
-TOTAL: 885ml To deliver fluids
accurately and at
desired rate
Submitted By: Eben Ezar H. Dela Cruz, SMU-SN