1.

Risk for deficient Fluid Volume

ASSESMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION

Risk for deficient Fluid After 8 hours of Independent: After 8 hours of nursing
Subjective: Volume related to nursing care, client care, client was able to
“Naminduwa nak ingestion of suspected will be able to:  Monitor I and O. Note  Provides information maintain fluid volume at
nga agCR nga kasla contaminated food number, character and about overall fluid a functional level as
danum jy itaktakki possibly evidenced by  Maintain fluid amount of liquid stools; balance, renal function evidenced by most
kon. Kanayon nak active volume loss- volume at a estimate insensible fluid and bowel disease mucous membranes,
py nga agsarsarwa diarrhea and vomiting functional level as losses ; measure urine- control, as well as good skin turgor, and
kadetoy nga evidenced by specific gravity and guidelines for fluid capillary refill; stable vital
Dominggo.” as most mucous observe for oliguria. replacements. signs; and balanced
verbalize by the membranes, good  Assess vital signs (Blood  Hypotension (including intake and output with
patient skin turgor, and pressure, pulse, postural), tachycardia, urine of normal
capillary refill; temperature) and fever can indicate concentration and
Objective: stable vital signs;  Emphasize to increase response top and effect amount; identify
>Passed watery and balanced fluid intake especially of fluid loss. individual risk factors and
stools for three intake and output those containing with  Rehydration is the top appropriate
times already with urine of electrolytes. priority in diarrhea. interventions.
>Presence of normal  Reveals imbalances
abdominal cramps concentration and Collaborative associated with fluid
>Last meal the amount. and electrolyte loss
night prior to care  Identify individual  Monitor serial through vomiting and
was pork babacue risk factors and electrolytes and diarrhea.
to onset of appropriate metabolic panel.
symptoms interventions.  Administer IV fluids and
BP: 170/90 mmHg electrolytes, as indicated.
PR: 85bpm
RR: 21 cpm
T: 36.3 0C
Skin pinched
retract slowly
2. Hyperthermia

ASSESMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION

Hyperthermia related After 4 hours of Independent: After 4 hours of nursing
Subjective: to dehydration possibly nursing intervention, intervention, the patient
“Tallo nga aldaw evidenced by (Increase the patient will be  Monitor client  Temperature of 38.9 was able to demonstrate
nga agawan in body temperature able to: temperature- degree and 0C-41.1 0C suggests temperature within
agadda ti gurigor above normal range) pattern. Note shaking acute severe infectious normal range, from 38.4
kon.” As verbalize skin flushed and warm  Demonstrate chills or profuse disease process. Fever 0C to 36.5 0C- 37.5 0C,
by the patient. to touch. temperature diaphoresis. pattern may aid in and be free of chills;
within normal  Monitor environmental diagnosis. Chills often experience no associated
Objective: range, from 38.4 temperature. Limit or precede temperature complications
 Febrile. T: 38.4 0C to 36.5 0C- add bed linens, as spikes.
0C in both 37.5 0C, and be indicated.  Room temperature and
axilla. Skin free of chills.  Provide tepid sponge linens should be
flushed and  Experience no baths. Avoid use of altered to maintain
warm to touch, associated alcohol. near-normal body
skin pinched complications. temperature.
retracts slowly. Collaborative:  Tepid sponge baths
 PR: 88 bpm may help reduce fever.
 RR: 20 cpm  Administer antipyretics,  Antipyretics reduce
 Seen weak such as Paracetamol as fever by its central
per doctor’s order. action on the
hypothalamus; fever
should be controlled in
clients who are
neutropenic or
asplenic.