Medical Diagnosis: Deficient fluid volume PRIORITY #1: Deficient fluid volume related to fluid loss secondary to diarrhea ASSESSMENT Subjective >Client reports dryness of her oral mucosa Objective >Vital signs T:35.4 PR:60 RR:22 BP:100/60 >pale conjunctiva >normal appetite >has intermittent fever >decreased skin turgor >normal capillary refill time >elevated WBC count >Provide comfort measures >Ensure that the client is receiving right amount of maintenance fluids. PLANNING Short-term goal INTERVENTION RATIONALE Independent >Assess for the signs of >To determine the cause At the end of this shift, the dehydration including skin of pharyngeal pain. This client exhibit signs of turgor, oral mucosa, etc. will provide a data that improvement in hydration could be used to evaluate status. the proper intervention that the client needs. >Review ways to improve the client’s hydration status >Encourage the client to increase the fluid intake. >Monitor I & O and IV fluids >Keep a quiet environment and calm activities. >Provide health teachings on avoidance of dehydration >To reduce the dryness of the oral mucosa >To determine if IV fluid and electrolyte replacement are needed >To reduce stress and anxiety >To promote awareness on related factors EVALUATION After doing the necessary nursing interventions and teachings, the client: >Achieved appropriate urine output >Participated in health teaching Age: 22 Gender: Female

>Followed the prescribed pharmacological regimen. >Demonstrated use of relaxation skills to reduce anxiety

know. mother. the help of SO or learning plan and actions questions: information in all caregivers to learn. ASSESSMENT PLANNING INTERVENTION RATIONALE EVALUATION Subjective: Short term goal: >Assess level of >Some clients may need >Client responded to the >Verbalization of >Assist client to use given knowledge of the client. >Reinforcement learning >Vital signs (e. other family process allows the client to T:35.• PRIORITY #2: Deficient knowledge (Learning need) regarding electrolyte imbalance as evidenced by verbalization of questions and concerns. RR:22 accurately and clearly.4 members) proceed at her own pace. >Client was able to deal PR:60 >Give information with her anxiety. performed. progressing from simple to complex. capable at this time. “Ano bang causes ng applicable areas including dehydration at environmental causes >Determine the client’s >Client might not be gastroenteritis?” readiness and barriers to physically or emotionally >Client provided a >Provide information and learning. (pathophysiology) >Begin with the info the >Can arouse interest/limit client already know and sense of being move to what she does not overwhelmed. positive feedback and self-learning modules adherence to the teaching. BP:100/60 >Teach the client to cease >To give awareness on the alcohol consumption possible complications of >Inaccurate understanding because of the possible having vices of her disease’ complications.g. Objective: regarding her disease >Identify support persons. .

wrestler. >To help the client to have a control on her eating habits. including: high carbohydrates. Samoan) attaining the desirable body weight with an >Sedentary lifestyle is optimal maintenance of frequently associated with health. and joining in an exercise programs/ >Inform the client the proper amount and kind of food that she needs to eat.PRIORITY #3: Imbalanced Nutrition: Less than body requirements related to inadequate intake and fluid loss secondary to vomiting and diarrhea ASSESSMENT PLANNING INTERVENTION RATIONALE EVALUATION Subjective: “Ang laki ng pinayat ko. >Client verbalizes her goals by changing her eating patterns. and solid to semi-solid foods. obesity and is a primary focus for modification.” >Decrease food intake >Reported presence of nausea in the morning Objective: >Vital signs T:35. Independent: >Obtain commitment for achieving desirable weight. liquids with high electrolyte content.g. >Verbalize adherence to (e. food quantity/quality. low fat and protein. After 8 hours of nursing care/teaching. football the plan of teaching for lineman. patient has: >Familial traits or cultural beliefs may place high importance on food intake as well as large body size. .4 PR:60 RR:22 BP:100/60 >decrease 5% of the weight >Poor skin turgor >Pale conjunctiva Short term goal: >Assess risk/presence of conditions associated with rapid weight loss >Encourage client to adhere to her prescribed diet (55:20:25) >Provide information regarding her specific nutritional needs.

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