ATENEO DE NAGA UNIVERSITY

COLLEGE OF NURSING

ASSESSMENT DIAGNOSIS RATIONALE PLANNING INTERVENTION RATIONALE EVALUATION

After 6 hours of After 6 Hours
Subjective data: Fluid volume Electrolytes regula nursing - Monitor - CVP of nursing
“madalas po ako deficit related te nerve intervention the vital signs measureme intervention the
umhi pero pero to active fluid and muscle functio client was able and CVP. nts are client was able
konti lang ako loss and n, hydrate the to Note useful in to
uminom ng decreased fluid body, presence of determinin
tubig” as intake balance blood acidi - Maintain postural BP g degree of - Increas
verbalized by ty and pressure, fluid changes fluid deficit e
patient and further rebuild volume and and urinary
damaged tissue. at a observe for response to output
Objective data: Sodium, calcium, functional fever replacemen - Moist
- Generaliz potassium, level t therapy. mucous
ed body chloride, - Adequate Fever membra
weakness phosphate, and urinary increasing ne
- Episodes magnesium are all output metabolism - Patient
of electrolytes. When with and still
shortness these substances normal exacerbate experie
of breath become specific s fluid loss nces
- Dry oral imbalanced, it can gravity episode
mucosa lead to either - Vital - Monitor - Fluid of
- Decrease muscle weakness signs are urinary replacemen tachycar
d skin or excessive stable output. t needs are dia and
turgor contraction. - Moist based on shortnes
mucous correction s of
membran of current breath.
e and deficits and
good skin ongoing
turgor losses

- Assess for - To
the signs of determine
dehydratio the cause
n including of
skin turgor pharyngeal
and oral pain
mucosa

- Encourage - To reduce
the client the dryness
to increase of the oral
the fluid mucosa
 intake

- To
- Monitor I &
determine
O and IV
if IVF and
fluids
electrolyte
replacemen
t are
needed

- To reduce
- Keep a
stress and
quiet
anxiety
environme
nt and
calm
activities

- To promote
- Provide
awareness
health
on related
techniques
factors
on
avoidance
of
dehydratio
n