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Jordan G.

Aguilar BSN 103- FEU Cues S: konti plang ang naiinom ko, nakakadala wang baso plang ngayong araw na to He is advised to have a DAT diet. But still doesnt have any intake of solid food. O: Dry lips, Poor skin turgor Health Problem Deficient fluid Volume related to insufficient knowledge as manifested by dry lips Analysis Fluid volume deficit, or hypovolemia, occurs from a loss of body fluid or the shift of fluids into the third space, or from a reduced fluid intake. Common sources for fluid loss are the gastrointestina l (GI) tract, polyuria, and increased perspiration. Fluid volume deficit may be an acute or chronic condition managed in the hospital, outpatient center, or home setting. Goals and Objectives Goal: after nursing interventions, the client will be able to have adequate intake of fluids as manifested by good skin turgor. Objectives: the client will be able to: a. verbalize understanding of causative factors and purpose of individual therapeutic interventions and medications Nursing Interventions Independent: Assess vital signs, including temperature and respirations. Observe urinary output, color, and measurement amount and specific gravity. Rationale Evaluation The client will be able to have adequate intake of fluids as manifested by good skin turgor. To more accurately determine replacement needs. Early identification of risk factors can decrease occurrence and severity of complications associated hypovolemia. These signs indicate sufficient dehydration to cause poor -The client was able to show good skin turgor and moist lips. - verbalized understanding in sufficient fluid intake.

Discuss factors related to occurrence of deficit, as individually appropriate.

b. demonstrate behavior to monitor and Note change in

The therapeutic goal is to treat the underlying disorder and return the extracellular fluid compartment to normal. Treatment consists of restoring fluid volume and correcting any electrolyte imbalances. Early recognition and treatment are paramount to prevent potentially lifethreatening hypovolemic shock. Elderly patients are more likely to develop fluid imbalances

correct deficit

usual mentation and functional abilities.

cerebral perfusion and electrolyte imbalance. Encouraging patient to increase fluid intake will help the patient and prevent from severe dehydration. Explaining the importance of proper nutrition a hydration will encourage the patient to maintain his or her proper nutrition and hydration. To prevent injury from dryness.

Encourage patient to drink prescribed fluid amounts.

Explain importance of maintaining proper nutrition and hydration.

Provide frequent oral and eye care. Limit the

To determine that tends to exert a diuretic effect.

intake of alcohol and caffeinated beverages. Establish 24hour replacement needs and routes to be used. Dependent: Assist with treatment of underlying conditions causing or contributing to dehydration and electrolyte imbalances. Administer fluids and electrolytes as indicated. Administer or discontinue medications as indicated.

Steady rehydration over time prevents peaks in fluid level

Fluids used for replacement depend on 1)the type of dehydration present and 2) The degree of deficit determined by age, weight, and type of condition causing the deficit. To determine whether the disease process or medications are contributing to dehydration.

Collaborative : Administer doctors order. Clarify doctors order if there is questionable data. Confirm to other health care provider. Review laboratory results.

I. Physiologic A. Deficit

1. Impaired Physical Mobility

Impaired physical mobility, inability to stand alone related to skeletal impairment to facture of the right femoral

Fractures occur when the bone is subjected to stress greater that it can absorb. When the bone is broken, adjacent

After 8 hours of holistic nursing caring care the patient will be able to:

Measures to: 1. Promote adequate mobility of the client.

1. demonstrate - instruct the 5.0 to keep increasing function of the side rails up or

-to avoid patients from falling to sudden

Cues: - Difficulty in changing position while lying on bed. -Difficulty in moving the extremities. -Inability to walk or stand alone. -limited range of motion in the extremities. -Slowed movement. -Difficulty initiating gait. dili gihapon mu lihok akong tiil day as verbalized by the patient.


structures are also affected, resulting in soft tissue edema, hemorrhage into the muscles and joints, joints dislocations, ruptured tendons, severed nerves, and damaged blood vessels. Body organs maybe injured by the force that caused the fracture fragments. After a fracture, the extremities cannot function properly because normal functions of muscle depend


rose. - assist patient to do active ROM exercises on the lower extremities.

movements -to improve muscle strength and joint mobility

-Provides comfort measures such as backrub. -Encourage patient to stand or walk as tolerated using parallel bars. -Support affected body parts or joints using pillows or rolls. -administer pain reliever such as areoxia as prescribe by

-in order for the patient to become more relax and comfortable -in order for the muscle to be more relax and relieves the pain

-to relieve pain and motion

on the integrity of the bones which they are attached.

the physician. -Consult with physical or occupational therapist as indicated.


-to develop individual exercise or mobility program and identify appropriate adjunctive devices.