HIGHLY PRIORITIZED: Rehydration, to restore fluid volume and correcting any electrolyte imbalances

Nursing Problem: Diarrhea, Vomiting

Nursing Diagnosis: Deficient fluid volume related to active fluid loss ( diarrhea and vomiting)
Subjective/ Objective Related Labs and Short Term Goal Interventions Rationale Evaluation
Cues Related Durgs
Subjective Cues: Related Labs: After 8 hrs. of duty and 1.)Determine the effects of age. -Elderly individuals are at high risk because of Goal was met.
“ 5 beses akong nagtae Chemistry appropriate nursing decreasing response/ effectiveness of
@ 6 na beses ding Hematology care interventions, the compensatory mechanism After 8 hrs. of duty and
nagsuka kagabi, mula Urinalysis patient will be able to 2.)Compare usual and current weight -Indicator of overall fluid nutritional status appropriate nursing care
11pm hanggang 1:17am Parasitology maintain the fluid 3.)Advice intake of foods with high fluid -To provide hydration interventions, the patient
kaya dumeretso na volume at functional content was able to maintain her
kami dito”. As Related Drugs: level by: 4.)Measure client’s output -To ensure accurate data of fluid status fluid volume in functional
verbalized by the IVF of 1L LR 5.)Encourage change in position frequently -To prevent stasis and reduce risk of tissue level as evidenced by:
patient. – fluid replacement 1.)Note physical signs injury
associated with 6.)Provide optimal skin care -To prevent injury from Dryness 1.)Physical signs associated
Objective Cues: Ciprofloxacin 2x/day dehydration. 7.)Provide frequent oral and eye care -To prevent injury from Dryness with dehydration is noted
-dry skin and dry lips 500mg 1cap 2.)Establish 8 hrs. fluid 8.)Discuss factors and ways to prevent -To educate the patient and examined
-body malaise -Antibiotic to treat replacement, needs, dehydration 2.)Establish 8 hrs. fluid
-paleness Bacterial infections and routes, as ordered. 9.)Assist client to measure her own intake and -Help determine baseline symptoms replacement, needs, as
-restlessness Dupatadin 3x/day 10g 3.)Promote comfort and output ordered
V/S: 1tab safety of the patient 10.)Recommend restriction of caffeine and -To prevent frequent Urination 3.)Comfort and safety of
T- 36.6˚C -Abd. pain 4.)Promote wellness alcohol the patient was promoted
P- 73 bpm Plasil 10mg 3x/day for 5.)Health teaching on 4.)Wellness promoted
R- 21 cpm 10days patient on how to attain DEPENDENT 5.)The patient
BP- 1400/90 mmHg -ant- emetic normal hydration 11.)Administer IV fluids as Indicated -Fluids may be given in this manner, if client is demonstrated proper
Pantoloc 40g 1x/day for status. unable to take oral fluid, or when rapid fluid understanding on the
5days 6.)Maintain normal resuscitation is required. health teaching
-anti-ulcer fluid volume and 12.)Administer medications as ordered -Antiemetics or antidiarrheals limit gastric/ 6.)Fluid volume was
Hydrase 2x/day for 5 replace fluid loss. intestinal losses improved and maintained
days 13.)Review laboratory data -To evaluate degree of fluid and electrolyte
- imbalance and response to therapist
14.)Giving advice on the patient to increase -To promote understanding and avoid
fluid intake. reoccurrence of Illness
15.)Encourage increase oral fluid intake -To reduce risk of skin breakdown