Assessment Diagnosis Scientific Objectives Intervention Rationale Evaluation

Explanation
S: “medyo nasususka Deficient Fluid After 8 hour of  Assess vital  Vital signs After 8 hour of nursing
po ako.” volume less than Frequent watery nursing signs, noting changes such as intervention the client
body stool intervention the low blood increased heart was able to:
O: requirements  client will be able pressure, rate,
 Concentrated related to Hyperactive bowel to: sever decreased blood Short term:
urine dark passage of watery sounds hypotension, pressure, and  Maintained
yellow stool, nausea and  Short term: rapid increased adequate fluid
 Weakness vomiting as watery and  Maintain heartbeat temperature volume at a
 Dry skin evidenced by greenish in color adequate and thread indicate functional level as
 Dry mucous weakness and  fluid volume peripheral hypovolemia. Hyp evidenced by
membrane poor skin turgor. Introduction of at a pulses otensive and adequate fluid
 Pale bacteria into the GI functional increased pulse volume and
conjunctiva tract level as rate can be an electrolyte
 Pale nail beds  evidenced indication that balance as
 Capillary refill Release of by adequate patient is evidenced by
more than 3 bacterial toxins fluid volume dehydrated. urine output
seconds  and greater than 20 ml
 Soft and Disrupts the electrolyte per hour
watery stool mucus lining of the balance as  Observe and  Dark greenish
Vitals signs stomach evidenced measure brown indicate
 BP 110/80  by urine urinary concentrated.
 RR 20 Release of HCl output output
 PR 63 cause gastric greater than (hourly/24 Long term
 Temp 36.4 irritation 20 ml per hour total)  The patient will
 hour Note color manifests weight
Increase gastric gain
motility/peristalsis  Showed no signs
 of dehydration
Increase gastric
motility Long term  Continue  Indicates
  The patient monitoring excessive fluid
Frequent will manifest intake and loss or resultant of
defecation weight gain output(accur dehydration.
  Shows no ately), Accurate records
Increase loss of signs of character, are critical in
water and dehydration and amount assessing the
electrolytes of stools, patient’s
 vomiting and fluid balance
Diarrhea bleeding

Reference:
Medical nursing  Monitor for  Potassium is vital
by Gettrust neurologic electrolyte for
and skeletal and
neuromuscul smooth muscle
ar manifestati activity.
ons
of hypokalem
ia (e.g.,
muscle
weakness,
lethargy,
 altered level
of
consciousne
ss)

 Provide  Oral hygiene can

oral hygiene. increase patient’s
By means of appetite for eating
teaching and interest in
patient drinking essential
to brush amount of fluid
teeth thrice a
day or every
after meal.
(Use
soft bristle to
prevent
bleeding
episodes

 Provide  To prevent injury

frequent eye from dryness
care

 Encourage  Oral fluid

patient to replacement is
 drink indicated for mild
fluid deficit

Reference:
(Nursing Care Plans, 9th
Edition, Doenges,
Moorhouse & Murr,
p.325-326 2014)

Health Teaching:
 To replace the lost
 Instruct the
fluids and
family to give
electrolytes orally
the client a
drink 2-3
liters/day

Collaborative:

Administer
Intravenous fluids
as prescribed.
 Lactated  To deliver fluids
Ringers accurately and at
125cc/hr desired rates

 Oral  To rehydrate the

Rehydration
 Solution patient

Still for Laboratory

result:

CBC with APC  Provides

information about
 Monitor
hydration and
laboratory organ function.
studies: Significantconseq
Hgb/Hct, uences to
electrolytes, systemic function
protein are possible as a
result of fluid
shifts,
hypovolemia,
hypoxemia,
circulating toxins

Reference:

(Nursing Care Plans, 9th

Edition, Doenges,
Moorhouse & Murr,
p.325-326 2014)