ASSESSMEN T Subjective: “Bigla akong nanghina bago ako dalhin sa ospital. Akala ko matutuluyan na ako.

” The client verbalized. Objective:  Low blood pressure: - 90/60 mmHg  Altered Serum sodium: - low: 136.00 mmol/L

NURSING DIAGNOSIS Deficient fluid volume related to diarrhea

ANALYSIS

GOALS AND OBJECTIVES Goal: After the nursing interventions, the client will be able to maintain fluid volume at a functional level as evidenced by individually adequate urinary output with normal specific gravity, stable vital signs, moist mucous membranes, good skin turgor, and prompt capillary refill. Objectives: 1. Assess causative/ precipitating factors

NURSING INTERVENTIONS

RATIONALE

EVALUATION After the nursing interventions, the client was able to maintain fluid volume at a functional level as evidenced by individually adequate urinary output with normal specific gravity, stable vital signs, moist mucous membranes, good skin turgor, and prompt capillary refill.

• Note possible conditions/ process that may lead to deficits • Determine effects of age

• To determine the underlying cause of the disorder • Very young and extremely elderly individuals are quickly affected by fluid volume deficit, and are least able to express need • To determine the current of status of the client

• Evaluate nutritional status, noting current intake, weight changes, problems with oral intake, use of supplement/tube feedings 2. Evaluate degree of fluid deficit • Assess vital signs

• Note change in usual mentation/ behavior/ functional abilities

• To provide baseline data with regards to the current status of the client. • These signs indicate sufficient dehydration to

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