CUES

NURSING DIAGNOSIS PROBLEM: Fluid Volume Deficit ETIOLOGY: Active fluid volume loss SIGNS AND SYMPTOMS: As manifested by 6-7 episodes of loose watery with particles stool, moderate in amount and scanty. Bulging when supine secondary to intestinal colic,

RATIONALE

NSG. OBJECTIVE SHORT TERM GOAL: After 30 minutes – 1 hour of nursing care, the patient will be able to restore its normal circulating body fluids

NSG INTERVENTION INDEPENDENT 1. Establish and encourage needs such as frequent oral needs like water, juices, and Gatorade. 2. May restrict diet for age except oily foods

RATIONALE

EVALUATION

SUBJECTIVE:

Nung bago kami ma-admit dito sa hospital, sumusuka siya ng 3 beses at dumudumi ng madami. Pero ngayon hindi na siya sumusuka. Nagtatae naman siya ng basa tapos makalat, madaming beses na, nakaka 6-7 na siyang dumi, minsan konti, minsan madami. Lagi niya sinasabi na masakit daw

Pathogens cause tissue damage and inflammation by releasing endotoxins that stimulate the mucosal lining of the intestine resulting in the greater secretion of water and electrolytes into the intestinal lumen. The active secretions of chloride and bicarbonate ions are the small bowel

Helps in fluid replacement from active loss of fluids

SHORT TERM GOAL: After 30 minutes of rendered care, the patient had restored his body’s circulating fluids. (goal met) LONG TERM GOAL: After 1 day of rendered nursing care, the patient had maintained optimum normal circulating body fluids as

To allow bowel rest and reduced intestinal workload To prevent stress and anxiety that may induced peristalsis To replace loss of water and for rehydration Maintain hydration and electrolyte

LONG TERM GOAL: After 1 day of rendering nursing care, the patient will able to reestablish and maintain body fluids as will be

3. provide comfort measures

4. Increase oral fluid intake

5. Proper regulation of IVF

tiyan niya tapos ang tigas ng tiyan niya parang ang daming kabag.

OBJECTIVE: >6-7 episodes of loose watery with particles stool, moderate in amount and scanty. >Bulging when supine secondary to intestinal colic and tenderness of the stomach >hyperactive bowel sounds is heard >dry lips

hyperactive bowel sounds is heard, dry lips and eyes are slightly sunken and teary as verbalized by the mother “Nung bago kami ma-admit dito sa hospital, sumusuka siya ng 3 beses at dumudumi ng madami. Pero ngayon hindi na siya sumusuka. Nagtatae naman siya ng basa tapos makalat, madaming beses na, nakaka 6-7 na siyang dumi, minsan konti, minsan madami.

leads to the inhibition of sodium reabsorption. To balance the excess sodium, large amounts of protein rich foods fluids are secreted in the bowel’s ability to reabsorb the fluid and leading to diarrhea.

manifested by decrease BM per shift, lips are no longer dry, no intestinal colic and no tenderness of the stomach, and eye is not sunken.

balance DEPENDENT: 1. Administer food supplement drugs (prozinc,5ml/OD)

It helps to strengthen the immune system. It helps to maintain balance of WBC and RBC in the blood. Because, the client has infection therefore the WBC is increased. Bacillus clausii is a good bacteria in our body. These drug contains of billions of good bacteria, it helps to populate our GIT of good bacteria and outnumbering those pathogenic or disease causing

evidence by negative BM per shift, lips are no longer dry, no tenderness of stomach, intestinal colic is decrease and eye is no longer sunken (goal met)

2. Administer anti-diarrheal medications (Erceflora 1 bottlet, BID)

> eyes are slightly sunken and teary

Lagi niya sinasabi na masakit daw tiyan niya tapos ang tigas ng tiyan niya parang ang daming kabag.

microorganisms such as amoeba, bacteria

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