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Published by unsp3akabl3

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Categories:Types, School Work
Published by: unsp3akabl3 on Sep 16, 2010
Copyright:Attribution Non-commercial


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Assessment NursingDiagnosisBackgroundKnowledgeSituationalNursing Goal &ObjectivesNursingInterventionRationaleEvaluation
Nagtatae at Nagsusukaasverbalized by the patient- Weak inAppearance- (+) Vomiting- Rashes noted atthe back Vital Signs:BP: 100/80PR: 87 bpmRR: 22 cpmTemp.: 37°CFluid VolumeDeficit r/t activevolume loss (activefluidloss(prolongedloose, unformedstool andvomiting), asevidenced by:Immediate Cause:Active fluid loss(prolonged loose,unformed stool andvomiting), asevidenced by:IntermediateCause: Bacterial/viral processPrimary Cause:Contaminated foodand water.HealthImplications:Complications of diarrhea of thediarrhea include the potential focardiacdysrhythmias because osignificant fluidand electrolyte lossAt the end of 8 hour shift the patient will be able to maintainfluid volume at afunctional level asevidenced by stablevital signs (PR),moist mucusmembranes, goodskin turgor and prompt capillaryrefillObjectives:After nurse –  patient interaction,the patient will beable to:1. Manifest stablevital signsIndependent:Monitor vitalsignsTachycardia is present along with avarying degree of fluid deficit. Fever increasesmetabolism andexacerbates fluidloss.Goals met by theend of the shift the patient maintainfluid volume at afunctional level asevidenced by stablevital signs (PR),moist mucusmembranes, goodskin turgor and prompt capillaryrefill.Effectiveness:The patient wasable to manifeststable vital signs.
(especially loss of  potassium) Urinaryoutput of less than30 ml per hour for 2 to 3 consecutivehours muscleweakness paresthesia,hypotension,anorexia,drowsiness with alow potassium levelDecrease potassiumlevels cause cardiacdsyrhythmias thatcan lead to death.(medical – surgicalnursing, Brunner &Suddarth’s, 10
edition, Vol.1, p.1032)Excessive fluid losscan lead tohypovolemic shock (medical – surgicalnursing, Brunner &Suddarth’s, 10
edition, Vol. 2, p.21312. Maintain accurateintake and output.3. Receiveappropriate fluidreplacement4. Manifest moistmucus membranes5. Manifest goodskin turgor a. Monitor intakeand outputa. Provide oralrehydrationtherapy frequentlyin small amounts. b. Replaceelectrolytes asorderedProvide frequentoral careEncouragerelatives of the patient to provide bath lessfrequently usingmild cleanser/soapand provideFluid replacementneeds are based oncorrection of currentdeficits and ongoinglosses.To replace the fluidlosses and preventfurther complicationlike severedehydration.To preventmetabolicimbalance andacidosisTo prevent injuryfrom drynessTo maintain skinintegrity and prevent excessivedrynessEffectiveness:The patient wasable to maintainaccurate intake andoutput.Effectiveness:The patient wasable to receiveappropriate fluidreplacement.Effectiveness:The patient wasable to manifestmoist mucusmembranesEffectiveness:The patient wasable to manifestgood skin turgor 

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