Assessment

Planning

Nursing

Rationale

Evaluation

Interventions
Subjective:Mabilis Short Term:
ako mauhaw pero

After 3 of NI,

di ako madami

patient shall

uminom kase taas

have verbalized

yung blood sugar

understanding of

ko as verbalized

causative factors

by the patient.

and purpose of
individual

Objective:
elevated

therapeutic
interventions and

temperature

medications.

of

Long Term:

38.4C/axilla

After 2 days of

increased
urine output.
sweating
of the skin
thirst
exhaustion
weight loss
dry skin or
mucous
membrane

NI, the patient

shall have
maintained fluid
volume at a
functional level
as evidenced by
individual good
skin turgor, moist
mucous
membrane and
stable vital signs.

Establish

Friendly

ShortTerm:

rapport

relationship

After 3 of NI,

Take and

with patient

patient will have

record vital

and to be able

verbalized

signs

to each others

understanding

Monitor the
temperature

concern

Assess skin
turgor and

To obtain
baseline data

To monitor

mucous

changes in

membranes

temperature

for signs of

dehydration

Dry skin and

mucous
membranes

Encourage
the patient

are signs of

to increase

dehydration

of causative
factors and
purpose of
individual
therapeutic
interventions
and
medications.
Long Term:
After 2 days of

To replace fluid

NI, the patient

Administer

loss and

will have

IVF as

prevent

maintained fluid

ordered by

dehydration

volume at a

fluid intake

the Doctor

electrolytes

Administer
anti-pyretic
as

To replace
and fluid loss

To decrease

prescribed

body

by the

temperature

Doctor.

and will have

less
occurrence of
dehydration.

functional level
as evidenced by
individual good
skin turgor,
moist mucous
membrane and
stable vital
signs