NURSING GOAL AND

ANALYSIS INTERVENTION RATIONALE EVALUATION

DIAGNOSIS OBJECTIVES

Risk for deficient Deficient Fluid After 8 hours of nursing INDEPENDENT:

fluid volume Volume is decrease interventions, the
related to d intravascular, patient will maintain ♦ ♦ ♦
inadequate fluid adequate fluid volume Monitor intake and Provides information After nursing
interstitial, and/or
intake as evidence as evidenced by good output, character, about overall fluid interventions the
by poor skin turgor. intracellular fluid. skin turgor and balance and amount of stools; balance, renal function, client has a baseline
This refers to intake and output. estimate insensible and bowel disease data for further
SUBJECTIVE: dehydration, water fluid losses. Measure control, as well as assessment and
 Nauuhaw loss alone without OBEJCTIVES: urine specific gravity guidelines for fluid measurement.
ako. change in sodium. 1. After 10 and observe for replacement.
mins of oliguria.
 Basa palagi nursing
ang tae ko. Nurses Pocket intervention ♦ ♦ ♦
Guide p.90 , the client Assess vital signs (BP, Hypotension (including After nursing
 Masakit Marilynn E. will pulse, temperature). postural), tachycardia, interventions the
palagi ang Doenges ,Mary verbalize fever can indicate client will has a data
abdomens Frances understandi response to or effect about her vital signs.
ko yung Moorhouse, Alice C. ng of of fluid loss.
lower part. Murr drinking
water in ♦ ♦ ♦
maintaining Observe for Indicates excessive fluid After nursing
Objective Cues: our body excessively dry skin loss or resultant of interventions the
 thirst and mucous dehydration. client
membranes, Fluid intake shall
 decreased 2. After 15 decreased skin t increase her fluid
skin turgor mins of turgor, slowed intake and have a
 nursing capillary refill. moist skin.
 weakness intervention
, the client ♦ ♦ ♦
will increase Weigh daily. Indicator of overall fluid After nursing
her fluid and nutritional status interventions the
VS taken as follows: intake. client
Weight is measured.
Temperature:37.9
♦ ♦ ♦
Pulse rate:79 Maintain oral Colon is placed at rest for After nursing
restrictions, bed rest healing and to decrease interventions the
BP: 130/90 and avoidance intestinal fluid losses. client
of exertion. Shall maintain bed
Respiratory rate: 19 rest and avoid
exertion of effort