Assessment

Objective:
-Patient has
poor skin
turgor
-V/S taken as
follows:
T-36.6
RR-24
PR-89
O2 SAT-99%
BP-130/90
INTAKE- 950
OUTPUT-3000

Diagnosis
Risk for fluid
volume
deficit r/t
excessive
losses
through
normal
routes.

Planning
After 4 hours
of nursing
intervention
patient will
demonstrate
adequate
fluid balance
as evidenced
by normal
skin turgor
and lowered
urine output.

Intervention
1.Assess the
patients
condition.
2.Monitor and
record vitals
3. Monitor I &
O

Rationale
To assess
causative
factors
To obtain
baseline
factors
To determine
any increase
or decrease
in fluids.
4. Encourage To decrease
increased oral risk of fluid
fluid intake
volume
After 8 hours
5. Educate
deficit.
of nursing
patient on the So that
intervention,
risk factors
patient can
patient will be that could
make life
able to
lead to fluid
style
identify the
volume
changes that
risk factors
deficit.
would
that could
prevent fluid
lead to fluid
volume
volume
deficit.
deficit.

Evaluation
After nursing
intervention,
patient was
able to
demonstrate
adequate fluid
balance as
evidenced by
normal skin
turgor and
lowered urine
output, also
patient was
able to
identify the
risk factors
that could
lead to fluid
volume deficit.