NURSING DIAGNOSIS Risk for deficient fluid volume related to inadequate fluid intake as evidence by poor skin turgor

. SUBJECTIVE:  Nauuhaw ako.  Basa palagi ang tae ko.  Masakit palagi ang abdomens ko yung lower part.

ANALYSIS Deficient Fluid Volume is decrease d intravascular, interstitial, and/or intracellular fluid. This refers to dehydration, water loss alone without change in sodium.

GOAL AND OBJECTIVES After 8 hours of nursing interventions, the patient will maintain adequate fluid volume as evidenced by good skin turgor and balance intake and output. OBEJCTIVES: 1. After 10 mins of nursing intervention , the client will verbalize understandi ng of drinking water in maintaining our body

INTERVENTION INDEPENDENT:

RATIONALE

EVALUATION

Monitor intake and output, character, and amount of stools; estimate insensible fluid losses. Measure urine specific gravity and observe for oliguria.

Provides information about overall fluid balance, renal function, and bowel disease control, as well as guidelines for fluid replacement.

After nursing interventions the client has a baseline data for further assessment and measurement.

Nurses Pocket Guide p.90 Marilynn E. Doenges ,Mary Frances Moorhouse, Alice C. Murr

Assess vital signs (BP, pulse, temperature).

Hypotension (including postural), tachycardia, fever can indicate response to or effect of fluid loss.

After nursing interventions the client will has a data about her vital signs.

Objective Cues:  thirst  decreased skin turgor

2. After 15 mins of

Observe for excessively dry skin and mucous membranes, decreased skin t turgor, slowed

Indicates excessive fluid loss or resultant of dehydration.

After nursing interventions the client Fluid intake shall increase her fluid intake and have a

Colon is placed at rest for healing and to decrease intestinal fluid losses. Maintain oral restrictions. Indicator of overall fluid and nutritional status After nursing interventions the client Weight is measured.9 Pulse rate:79 BP: 130/90 Respiratory rate: 19 nursing intervention . After nursing interventions the client Shall maintain bed rest and avoid exertion of effort . Weigh daily. the client will increase her fluid intake. weakness VS taken as follows: Temperature:37. capillary refill. bed rest and avoidance of exertion. moist skin.

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