V.

NURSING CARE PLAN

ASSESSMENT Subjective: No Cues Objective: -vomiting -watery stools -Vital signs: CR- 128bpm Temp- 36.2 C RR- 32 breaths/min NURSING DIAGNOSIS Fluid volume deficit related to increase metabolic demand and insensible fluid loss through vomiting PLANNING After nursing intervention, the patient will be able to: - Achieve adequate hydration as evidenced by good skin turgor, moist mucous membranes and lips, no alteration in mentation NURSING INTERVENTIONS Assessed vital signs and degree of hydration and level of consciousness RATIONALE Provides baseline data and information; this is also important in the evaluating clients condition an success of intervention Adequate fluids will replace fluid lost through insensible water loss due to hyper metabolic state and vomiting EVALUATION After nursing intervention the patient was able to achieve adequate hydration. therefore the goal was met.

Encouraged adequate fluid intake as tolerated by the patient. Instructed SO to provide fluids in the bedside

 Regulated IVF according to specified flow rates basing on the physicians order

Regulation of fluid is critical in maintaining adequate circulating fluids to recover for the amount of water loss through fever and vomiting