Patient’s Name: Palon, Eduardo Name: Jesse James Edjec
Age: Group 2 BN3-N Sex: M Marital Status: CC: loose watery stool Medical Diagnosis: Acute gastroenteritis with moderate dehydration Date of Admission: May 5, 2010 Time of Admission: Assessment Data Nursing Rationale Desired Outcome Nursing Interventions Justification Evaluation Diagnosis Increase Output After 16hours of nurse-client Independent intervention, the client was Actual/Abnormal Fluid Volume (diarrhea) At the end of 16hrs nurse- able to: Findings deficit related to client intervention, the client loose watery Decrease in total will be able to: 1. Assess vital signs; note strength of -To evaluate degree of fluid peripheral pulses. deficit. Subjective: stool (Diarrhea) body water • Thirst AEB thirst, 1. Maintain fluid volume at a 2. Keep fluids within clients reach -to correct/ replace losses to • Weakness weakness, reductions in both the functional level as evidenced and encourage frequent intake as reverse pathophysiologic Objective: decreased urine intracellular and by individually adequate appropriate. mechanisms. • Decreased urine output, poor skin extracellular fluid urinary output with normal output turgor, BP- volumes specific gravity, stable vital 3. Control humidity and ambient air -To reduce high fever and 100/80, Pulse-84 signs, moist mucous temperature as appropriate. Reduce elevated metabolic rate. • Poor skin turgor membranes, good skin turgor beddings/clothes, provide tepid intravascular volume • BP-100-80 Definition: depletion and prompt capillary refill. sponge bath. • Pulse-84 Decreased Risk Related Factors 4. Change position frequently. -To promote comfort and intravascular, thirst, weakness, 2. Verbalize understanding of • Anxiety safety. interstitial, decreased urine output, causative factors and purpose • Infrequent fluid and/or poor skin turgor, of individual therapeutic 5. Provide safety measures when -To promote safety. intake intracellular decrease BP, increase interventions and medications. client is confused. Strengths fluid. This refers pulse rate and • Strong family to dehydration, temperature 3. Demonstrate behaviors to Collaborative -to limit gastric/intestinal support water loss alone monitor and correct deficit as 1. Administer medications as losses. indicated.(antidiarrheals) • Strong without sodium. Fluid Volume Deficit indicated. Compliance to 2. Establish 24-hour fluid -To prevent peaks/valleys in medications Definition: Reference: replacement needs and fluid level. Reference: http://emedicine.me routes to be used. Nurse’s pocket dscape.com/article/ Guide 9th edition 906999-overview 3. Administer IV fluids as -To replace losses to reverse indicated. pathophysiologic mechanisms.