Cues

Nrsg. Diagnosis

Pathophysiol ogy

Desired Outcome

Nrsg. Intervention

Rationale

Evaluati on

Reference

Subjectiv e:

Objective s: V/S : T: P: R: BP: >Dry skin and mucous membran e. > decrease skin turgor. >decreas e urine output. >body malaise. >change in mental status.

Dehydration: fluid volume deficit R/T inadequate intake of fluid and increase GI fluid loss and decrease urine output AEB : -dry skin and mucus membrane -V/S alteration : BP and PR Less output Weakness Change in mental status.

Within 5 days of duty the patient will be able to: Demonstrate improved fluid balanced AEB adequate urine output, stable vital signs, moist mucous membrane,an d good skin turgor. Establish good hydration habit. Verbalize understanding of causative factors and therapeutic regimen.

1. Monitor V/S of the patient. 2. Assess hydration status (capillary refill, status of mucous membrane and skin turgor).

3. Note change in neurologic status.

4. Monitor amount of fluid intakes and measure the output accurately.

1. To provide baseline data. 2. To determine the condition of the circulation of the patient. And also to determine if there is any alteration so that may given appropriat e interventi on. 3. Neurologic status may become evident in severe dehydrati on. 4. Pt. may abstain from all intakes resulting to dehydrati

After

5. Obtain daily weight

on. 6. Encourage pt. to increase fluid intake and continue IV infusion as physicians ordered. 7. Administer antimotility drugs.

5. To determine the hydration status .

6. To replace the fluid loss

7.