Assessment

Diagnosis

Scientific Explanation

Planning

Intervention

Rationale

Expected Outcome

S= O= Pt. manifested: >good skin turgor >urine output of 2x >no vomiting >loose watery stool 3x >VS: T: 36.7C P: 110bpm R: 32cpm

Risk for fluid volume deficit r/t excessive losses through normal routes.

The pt. is diagnosed with acute gastroenteritis or the inflammation of gastrointestinal tract. The inflammation is most often caused by infection with certain viruses, less often by bacteria or their toxins, parasites, or adverse reaction to something in the diet or medication. Common effects of gastroenteritis include N&V and diarrhea. Excessive vomiting and diarrhea can lead to dehydration which can be considered as fluid volume deficit.

Short Term: After 4 hrs of NI, the pt. will demonstrate adequate fluid balance as evidenced by stable VS, normal skin turgor, moist mucous membranes, & appropriate urine output. Long Term: After 2-3 days of NI, the pt. will to identify risk factors and appropriate interventions and demonstrate behaviors or lifestyle changes to prevent development of fluid volume deficit brought about by gastroenteritis.

>establish rapport

>to attain the trust & cooperation of the pt. & SO >to determine intervention to be performed >to obtain baseline data >to determine any increase/decrea se in fluids >to reduce risk of fluid volume deficit >to prevent development of microorganisms which can cause gastroenteritis >to promote cleanliness to prevent growth of certain microorganism which can lead to infection.

>assess the pt.s condition >monitored & recorded VS >monitored I & O

Short Term: The pt. shall have demonstrated adequate fluid balance as evidenced by stable VS, normal skin turgor, moist mucous membranes & appropriate urine output. Long Term: The pt. shall have identified risk factors and appropriate interventions and shall have demonstrated behaviors or lifestyle changes to prevent development of fluid volume deficit brought about by gastroenteritis.

>encouraged increase oral fluid intake >instructed SO on proper food handling

>encouraged sanitation & hygiene